PROGRAM OF THE CONFERENCE
23th May 2008, Friday - Hall C
14.00 - 15.00
Opening session
Opening
Andrzej Cechnicki, Anna Bielańska
14.10 - 14.30
Jacek Bomba - "103 years of the Jagiellonian University Chair of
Psychiatry - a brief review"
14.30 - 15.00
Maria Orwid - "Cracow trauma studies"
KEYNOTE LECTURE
15.00 – 15.30
Norman Sartorius - "Community Psychiatry: an idea whose time has
gone?"
15.30 – 16.00
COFFEE BREAK
KEYNOTE LECTURES
Chair: Jacek Bomba
16.00 - 16.30
Stephan Priebe - "Love in the community? On the therapeutic
relationship in mental health service research"
16.30 - 17.00
Wulf Rössler - "Psychiatric Rehabilitation - Old wine in new skins"
17.00 - 17.30
Tillman Steinert - "Reducing coercion in psychiatry - a European
challenge"
17.30 – 18.00
Discussion
18.00
Welcome Party
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24th May 2008, Saturday
SYMPOSIA
9.00-10.45
1.
Mental Health Reform in Europe - Hall C
Chairman: Katarzyna Prot-Klinger/Petrea Ionela
1. David McDaid, Martin Knapp, Helena Medeiros and the MHEEN
Group “Barriers and opportunities for reform in central and eastern
Europe: Reflections from the mental health economics European
Network”
2. Katschnig Heinz, Mugur Ciumageanu, Dan Ghenea, Raluca Sfetcu
“Psychiatric reform in Romania from an EU and a Romanian perspective”
3. Katarzyna Prot-Klinger, Jacek Wciórka “Mental health program in Poland
– the important step to the implementation of the European psychiatry
values”
4. Guseppe Tibaldi “Surviving without the asylums in possible, but not
enough. Old and new walls in community psychiatry”
5. Grazia Zulian, Donisi V., Secco G., Battaglia G., Grigoletti L., Tansella
M., Amaddeo F. “Accessibility and utilization of mental health care
services”
2. Formal and informal coercion - Hall D
Chairman: Bogdan de Barbaro
1. Tom Burns “Paternalism in mental health: Time for reappraisal”
2. Ksenija Yeels, Tom Burns and the ULTIMA team Departament of
Psychiatry “Community treatment orders: Challenges in conducting an
RCT”
3. Kathryn Davis, Helen Nightingale, Tom Burns “What is the nature and
extent of informal coercion (ic) in mental health care?”
4. Rob van den Brink, Jan Broer, Fons Tholen, Wim Winthorst, Durk
Wiersma “Care contacts of individuals seen by the police for mental health
crises”
5. Martin Salzmann Erikson “The core characteristics and nursing care
activities in psychiatric intensive care units in Sweden”
6. Hans Joachim Salize, Harald Dressing “Care for Mentally Disordered
Persons in the European Prison Systems – the Eupris Study”
3. Outcome management and therapeutic relationship in mental health care - Hall A
Chairman: Bernd Puschner
1. Stefan Priebe, MECCA STUDY “Effects of Structured Communication in
Community Mental Health Care – More Findings from MECCA Study”
2. Sabine Steffen, Thomas Becker, Wolfgang Gaebel, Harald Freyberger,
Helmfried E. Klein, Tilman Steinert, Bernd Puschner „The therapeutic
relationship in a multicenter RCT on needs-oriented discharge planning
for high utilisers of psychiatric services“
3. Johan Håkon Bjørngaard „The impact of mental illness on patient
satisfaction with the therapeutic relationship-a multilevel analysis”
2
4. Bernd Puschner, Carina Knaup, Dorothea Schöfer, Thomas Becker “Short
and mid-term effectivness of outcome management in people with svere
mental illness”
5. Igor Hanuszkiewicz, Maria Wojnar, Andrzej Cechnicki “The role of
patient’s and therapist’s personality traits in the long-term psychotherapy
of patients with diagnosis of schizophrenia”
4. Stigma and mental illness 1 - Hall B
Chairman: Lars Hansson
1. Antonio Lasalvia, Bertani M., Bissoli S., Bonetto C., Cristofalo D., De
Santi K., Lazzarotto L., Marrella G., Mazzoncini R., Tosato S., Tansella
M. & Ruggeri M. on behalf of the PICOS-Veneto Group “Which barriers
do persons with psychosis perceive in their everyday life? A survey on
experienced and anticipated discrimination in first-episode psychosis”
2. Lars Hansson, Tommy Björkman, Bengt Svensson and the DIALOG
group “Beliefs of discrimination and rejection experiences among people
with schizophrenia living in the community. Results from the dialog
study”.
3. Liz Chisholm, Justine Schneider, Janet Betinis, Angela Smith, Torsten
Shaw, Philip Houghton, Anne Felton “Perceptions of social inclusion: a
mixed methods study of people with high support needs”.
4. Bertil Lundberg, Tommy Björkman “Stigma experiences among persons
with mental illness: Relationships to social network, self-related variables
and clinical characteristics”.
5. E. Brohan, R. Elgie, N. Sartorius, G. Thornicroft “The Gamian-Europe
stigma study: an international perspective on the experience of selfstigma”
6. Mieke Verhaeghe, P. Bracke, W. Christiaens “Stigma and client
satisfaction in mental health services”.
5. Occupational therapy and work - Hall S1
Chairman: Aart H. Schene
1. Urlika Bejerholm, Hansson L., & Eklund M. “Profiles of occupation
engagement in people with schizophrenia, poes: A new measure of time
use”
2. Louise Howard, Heslin M., Thornicroft G., de Salis I., Tomlin Z.,
Donovan J. “Avoiding under recruitment: lesson learned from an RCT”
3. Margaret Heslin, Howard L., Rice C., Leese M., Jarrett M., McCrone P.,
Spokes T., Thornicroft G. “The SWAN (Supported Work and Needs)
Study: AN RCT of Supported Employment”
4. Mona Eklund “Day – Care Centres for people with sMI – an intervention
project”
5. A.H. Schene, M.J. Kikkert, J.A. Swinkels, M.W.J. Koeter, P. McCrone
“Adjuvant Occupational Therapy for Work-related Major Depression:
Follow up of a Randomized Controlled Trial including Economic
Evaluation”
10.45 – 11.15
COFFE BREAK
11.15 – 13.00
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6. Community mental health services: problems and organization - Hall C
Chairman: Czesław Czabała
1. Mikael Sandlund, Urban Markström “The state and the implementation of
evidence based methods”
2. Claire Henderson, Jeffrey W. Swanson, George Szmukler, Graham
Thornicroft, Martin Zinkler “A typology of advance statements in mental
health care”
3. Donna T. Doherty, R. Moran “The use of health services and supports for
mental health problems in Ireland: Piecing together the jigsaw”
4. Lars Henrik Myklebust, Knut Sørgaard, Svein Bjorbekkmo, Alse Nymann,
Stian Molvik, Reidun Olstad “Psychiatric beds utilization in two
differently organized community mental health service systems. Northern
Norway. The Velo-Project.”
5. Stefanie Everaert, Gert Scheerder, Iris De Coster&Chantal Van
Audenhove LUCAS “Toward stepped care for people with depression:
Action research in community mental health centers”
6. Urban Markström, Rafael Lindqvist “Community mental health services in
Sweden – Organisational structure, inter-organisational relations and
service provision”
7.
Outcomes and new treatment strategies - Hall D
Chairman: Durk Wiersma
1. Durk Wiersma, Lex Wunderink, Sjoerd Sytema, Fokko J. Nienhuis
“Recovery and quality of life: relationship with symptomatic and
functional remission in first episode psychosis”
2. Andrzej Cechnicki “Long-term studies of early psychosocial intervention
in schizophrenia. 20-year follow-up.
3. Mirella Ruggeri, Bertani M., Lasalvia A., Bissoli S., Bonetto C., Cristofalo
D., De Santi K., Lazzarotto L., Marrella G., Mazzoncini R., Pellegrini N.,
Tosato S., Tansella M. on behalf of the PICOS-Veneto Group “Treatment
pathways for first-episode psychotic patients within community based –
mental health services in the Veneto region. Preliminary findings from the
Picos Project”
4. Harry Michon, Wilma Swildens, Jooske van Busschbach “Effectiveness
of the Psychiatric Rehabilitation approach In the Netherlands, two year
follow-up”
5. Helen Nightingale, Kathryn Davies, Tom Burns “Maintenance
antipsychotic medication: How much do patients and staff agree?”
8. Coercive treatment in psychiatry: A European research update - Hall A
Chairman: Thomas Kallert
1. Thomas Kallert “Predictors of involuntary hospital admission across the
eunomia study sites”
2. Matthias Schützwohl, Thomas W. Kallert and the EUNOMIA-study group
“Clinical and social outcomes of a) legally involuntary admitted patients
and b) legally voluntarily admitted patients who felt coerced at admission.
A comparison across the EUNOMIA study sites”
3. Rymaszewska Joanna, Andrzej Kiejna “Quality of life and social
functioning of involuntarily admitted patients – the EUNOMIA study”
4. Stefan Priebe and the Involve study group “One year outcomes of
involuntary hospital admissions in England”
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5. Jerker Hanson, Claes-Göran Westrin “Adverse events in psychiatry
identified by a no-fault patient – insurance
9. Assessment in mental health service - Hall B
Chairman: Jacek Bomba
1. Fiona Nolan, Sonia Johnson “A national investigation of mental health
inpatient staff morale in England”
2. Anke Bramesfeld “Measuring mental health services’ responsiveness to
service users expectations”
3. Leif Walhlqvist “What do They Really Do in Psychiatric Outpatient
Department?”
4. Torsten Munch-Hansen “National survey of in-and outpatients and their
relatives in Danish psychiatry”
5. Torleif Ruud, Rolf W Gråwe “Relatives more critical than patients to
services”
6. Derek King, Professor Martin Knapp “Associations between medication
non-adherence and resource use and costs for people taking medication for
depression”
10. Family context in research and therapy - Hall S1
Chairman: Dominika Dudek
1. Joanna Borowiecka – Kluza, Dominika Dudek “Family burden of patients
with affective disorders”
2. Sigrid Stjernswärd, Margareta Östman “E-health, depression and family
support”
3. Barbara Józefik, Maciej Pilecki, Dorota Okular, Dominika Pindus
„Perception of family relationships in eating disorders and depression implication for psychotherapy”
4. Józef Bogacz, Maria Wojnar, Andrzej Cechnicki „From familly
intervention to collaboration with familly” (film dvd)
5. Wojciech Kordas, Marta Janiszewska, Katarzyna Warchoł, Krzysztof
Walczewski “Normality restoring in the family. Case study”
13.00 – 14.30
LUNCH and POSTER SESSION
14.30 – 16.15
11. Vocational rehabilitation - Hall C
Chairman: Tom Burns
1. Goeff Shepherd, Helen Lockett, Miles Rinaldi „Developing EvidenceBased Employment Rehabilitation Services”
2. Justine Schneider “Social inclusion at work”
3. Hubert Kaszyński, Andrzej Cechnicki, Igor Hanuszkiewicz “Barriers to
work and employment of persons suffering from mental illness as viewed
by employers”
4. Miles Rinaldi, Rachel Perkins “The Individual Placement and Support
approach to vocational rehabilitation for young people with first episode of
a psychosis”
5. Tom Burns, Jos Catty, Thomas Becker, Durk Wiersma, Toma Tomov,
Angelo Fioritti, Wulf Rössler “Vocational rehabilitation in psychosis: The
eqolise trial”
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12. Measure of good practice - Hall D
Chairman: Łukasz Cichocki
1. Robert Hayword, “Mental Health Policy in a Global Context: Evidence–
based Research in Participatory Development“
2. Helen Killaspy “Development of a European of Best Practice for People
with Long Term Mental Illness in Institutional Care (DEMoBine)”
3. Christine Wright, Penelope Turton, Sarah White, Helen Killaspy
“Development of a European of Best Practice for People with Long Term
Mental Illness in Institutional Care (DEMoBine): A Deilphi Study To
Elicit The Opinions Of Key Staeholders”
4. Andrzej Kiejna, T. Adamowski, M. Ciałkowska, P. Piotrowski, J.
Rymaszewska “The Delphi Exercise in Poland”
5. Tatiana Taylor, Helen Killaspy, Michael King “Components of
institutional care for adults with longer term mental health problems: A
systematic review.”
6. Mojca Urek, Prof. Shulamit Ramon "Sensitivity for ethnicity and gender
issues in mental health organizations"
13. Instruments and methodology - Hall A
Chairman: Thomas Becker
1. Karin Ingvarsdotter, Sara Johnsdotter, Margareta Östman “Lost In
Interpretation Using interpreter in qualitative research”
2. Jerker Hanson, Marie Askerstam, Helena Forslund “CAN”as tool in longterm community based treatment”
3. Bengt Svensson, L. Hansson “User Participation in Research”
4. Louise Howard, L. Cole, S. Byford, M. Leese, J. Betts, S. Johnson “Do we
need a patient preference randomized controlled trial? Findings from a
patient preference randomized controlled trial comparing women’s crisis
houses and psychiatric hospital inpatient admission”
5. Svein Bjorbekkmo, Reidun Olstad, Lars Henrik Myklebust, Knut Sørgaard
“The Velo Study – Relations between Organization of Mentally Health
Services and Treatment Philosophy”
14. Beyond verbal intervention - Hall B
Chairman: Volkmar Sippel
1. Amanda Lundvik Gyllensten "The effects of Basic Body Awareness
Therapy in Psychiatric out-patient care"
2. Anna Bielańska “Theraputic theatre on the way to recovery”
3. V. Sippel, S. Berg, F.-M. Sadre-Chirazi-Stark “Could dramatherapy
improve the ability to recognize and express emotions for patients with
schizophrenia?”
4. Barbara Barret, Sarah Byford “The cost-effectiveness of group therapy in
community mental health services”
16.15 – 16.45
COFFE BREAK
16.45 – 18.00
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15. Stigma and mental illness 2 - Hall C
Chairman: Graham Thornicroft
1. Aliya Kassan, Nick Glozier, Morven Leese & Graham Thornicroft
“Changing medical education: Results of the anti-stigma training and
evaluation collaboration (astec) trial”.
2. Roshni Mangalore “Is there age-related inequality in the use of mental
health services in the UK?”
3. Tommy Björkman, Therse Angelman, Malin Jönsson „Attitudes towards
people with mental illness cross-sectional study among nursing staff in
psychiatric care and somatic caret”
4. Anita Bengston – Tops “Staff`s experiences and understanding of support
to abused woman with mental illness”
5. Gert Scheerder, Else Tambuyzer & Chantal Van Audenhove LUCAS
“Tackling mental health stigma: Evaluation of experiences in Belgium”
16. Residential alternatives to inpatient treatment - Hall D
Chairman: Maria Załuska/Maria Rostworowska
1. Brynmor Lloyd – Evans, S. Johnson, D. Osborn, H. Gilburt, M. Slade
“Acute inpatient wards and residential alternatives; A quantitative
comparison of service users` experience and satisfaction with services”
2. Charlotte de Heer - Wunderink, Annemarie D. Caro- Nienhuis, Sjoerd
Sytema, Ellen Visser, Durk Wiersma “Residential Care: Italina and Dutch
Residents Compared”
3. Louise Howard, E. Rigon, L. Cole, C. Lawlor, S. Johnson “Pathways to
admission for women admitted to women’s crisis houses compared with
psychiatric wards”
4. Helen Gilburt, Bryn Lloyd Evans, Sonia Johnson, David Osborn, Mike
Slade “The alternatives study – residential alternatives to hospital in the
UK”
5. Anna Serafin, Maria Załuska “PROGRESS” - model of holistic support of
youth suffering from severe mental disorders - as a element of psychiatric
community care service”
6. Myra Piat, David Bloom, Richard Boyer, Alain Lesage, Henri Dorvil
“Best Practices in the Provision of Housing for Persons with Serious
Mental Illness: Where do Consumers Want to Live?”
17. Social inclusion through work - Hall A
Chairman: Anna Bielańska
1. Finn Blickfeldt Juliussen “Service User Employee”
2. Stefan Watzke, Peter Brieger, Oliver Kuss, Henning Schoettke, Karl H.
Wiedl “Learning potential and rehabilitation outcome in schizophrenia: a
longitudinal study”
3. Tamara Shaw “Empowerment of mental illness service users: Lifelong
learning, integration and action”
4. Igor Hanuszkiewicz, Andrzej Cechnicki, Anna Bielańska, Hubert
Kaszyński “Social firms on the way to recovery” (film dvd)
5. Sophie Bellringer, Abigail Easter, Joanna Murray “From Exclusion to
Inclusion? Evaluation of Capital Volunteering”
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18. Treatment in community - Hall B
Chairman: Barbara Józefik
1. John Gale “The effects for therapeutic communities of changes in the
structure and funding of UK psychiatric and care”
2. Juan Jose Martinez Jambrina “The Aviles Model As A Guide For
Implementing The Assertive Community Treatment in Spain”
3. Marie Høgh Thøgersen „Assertive community treatment vs. standard
treatment for severe psychotic illness in Denmark: a quasi – experimental
trial”
4. Zavradashvili N., Donisi V., Grigoletti G., Gelashvili K., Eliashvili M.,
Amaddeo F. “Assertive community mental health service in Tbilisi
(Georgia)”
5. Bert-Jan Roosenschoon, Arina van der Kwaak & Moniek Bogaards
“Independent Living in the Community after Prolonged Hospitalization”
19.00
Visit at Wawel`s Cathedral with a special guide
20.00
GALA DINNER at Wawel Restaurant, Wawel Hill 9
25th May 2008, SUNDAY
9.00 - 13.00
Session Hall C
KEYNOTE LECTURES
Chair: Graham Thornicroft
9.30 - 10.00
Michaela Amering - "New forms of cooperations between users,
careers and mental health professionals in times of Empowerment
and Recovery"
10.00 - 10.30
Graham Thornicroft - "The relationships between anticipated and
experienced discrimination"
10.30 - 11.00
COFFEE BREAK
Chair: Bogdan de Barbaro
11.00 - 11.30
Tom Burns - "Getting back to work in Europe: the EQOLISE
psychosis study"
11.30 - 12.00
Bogdan de Barbaro - "'Soft coercion' in psychiatry"
12.00 - 12.30
Discussion
12.30
Aart H. Schene - Closing remarks
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ABSTRACTS
LECTURES
Community psychiatry: an idea whose time has gone?
Norman Sartorius
Department of Psychiatry, University of Geneva, Switzerland
Community care for people with mental illness was a revolutionary step forward when first
proposed. It seemed to be the right answer to many problems including that of overcrowded
large mental hospitals in which inmates were often kept in extremely poor conditions, were
subject to abuse, starvation and unnecessary limitations of their human rights.
Decades have gone by and emphasis on community psychiatry made it gain ground. Now that
this happened it is important to re-examine the notion of community psychiatry because of major
changes that have occurred in the structure of communities, in the nature of mental illness and
the therapeutic potential of psychiatry.
The presentation will open questions that arise in this respect and suggest that a major revision of
the strategy of mental health care (including the tenets of community care) is necessary.
Components of a possible new strategy will be proposed.
Love in the community? On the therapeutic relationship In Mental Health service research
Stephan Priebe
Unit for Social & Community Psychiatry, Barts and the London School of Medicine, Queen
Mary, University of London
The therapeutic relationship between the patient and the health care professional is at the centre
of mental health care delivery. Whilst this relationship has been extensively studied in
psychotherapy, there is less research on it in settings of community mental health care.
The presentation will provide an overview of concepts and theoretical models of the therapeutic
relationship in community psychiatry, summarise empirical findings on its role and predictive
value for outcome, and show how it can be assessed. A distinction will be made between the
relationship – i.e. an overarching and powerful psychological construct that is difficult to
measure and influence – and communication – i.e. an observable and assessable behaviour with
unclear significance. The two are interconnected: Positive communication may lead to good
relationships, and good relationships may facilitate effective communication. The presentation
will address how relationships and communication may be improved in practice and outline a
research agenda for how interventions in therapeutic relationships may be utilised to make
community psychiatry both more attractive and more effective.
Psychiatric Rehabilitation – old wine in new skins?
Wulf Rössler
University Hospital for General and Social Psychiatry Zurich
Lately we find the term “psychiatric rehabilitation” frequently used in the professional discourse
about long-term care and treatment. It is disappointing that this is more or less a discourse about
the old-fashioned institutions of sheltered living and working, i.e. only old wine in new skins.
A modern conceptualisation of psychiatric rehabilitation deals primarily with the person and not
with institutions. Today the goal of psychiatric rehabilitation is to help disabled individuals to
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establish the emotional, social and intellectual skills needed to live, learn and work in the
community with the least amount of professional support.
Modern rehabilitation practice changes the perception of mental illness. Enabling disabled
persons to live a normal life in the community causes a shift away from a focus on an illness
model towards a model of functional disability. As such, other outcome measures aside from
clinical conditions become relevant. Especially social role functioning including social
relationship, work and leisure as well as quality of life and family burden is of major interest for
the affected individuals living in the community.
In contrast to acute treatment there are mostly no legal powers to enforce psychiatric
rehabilitaion in long term care. Thus, the patients’ autonomy concerning treatment decisions and
their self-determination has to be respected. Within this frame, the therapeutic alliance plays a
crucially important role to engage the patients in their own care planning. It is essential that a
patient can rely on their therapists’ understanding and trust as most of the chronically mentally ill
and disabled persons loose close and stable relationships in the course of their disease.
Therefore, long-term rehabilitation is also an exercise in network building.
Reducing Coercion in Psychiatry - a European Challenge
Tilman Steinert
Centre for Psychiatry Weissenau, University of Ulm
Dept. General Psychiatry and Psychotherapy
The discussion about the use of coercive interventions such as seclusion and restraint
accompanies the history of psychiatry from its beginning. It is the oldest and still topical issue of
psychiatric institutions. Nowadays, the political growing together of Europe puts questions of
common ethical standards on the agenda. The quality of psychiatric care and particularly the use
of freedom-restricting coercive measures for mentally ill people are a challenge for modern
civilized societies. An overview is given about the use of coercive interventions in different
European countries in the past and the presence. European initiatives such as the CPT
(Committee for the Prevention of Inhumane or degrading Treatment or Punishment) are
presented. Available data on the use of coercive interventions in different countries were found
by literature review. The percentage of admissions exposed to coercive measures varies from
zero (Iceland) to more than 40 % (Netherlands). The median duration of a coercive measure
varies from 18 minutes (physical restraint, UK) to 16 days (seclusion, Netherlands). Obstacles
for decreasing coercion in clinical psychiatry are discussed. Suggestions for action are given:
• establish a sound database, comprising reasonable variables (including different forms of
coercion and violence)
• compare hospitals, units, different countries
• discuss frankly, learn from others
• establish education and training
• allow discussions with users and relatives
• set realistic goals
• facilitate independent controls of practice
• try alternatives und publish your experiences
New forms of cooperations between users, Carers and mental health professionals in times
of Empowerment and Recovery
Michaela Amering
Medical University of Vienna Department of Psychiatry and Psychotherapy
Context - Advocacy for empowerment and recovery has been joined by research offering new
perspectives on mental health policy, treatment, rehabilitation and anti-stigma efforts.
Objectives – Consequences and challenges of the substantial changes in settings and culture of
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therapeutic contacts with empowerment and recovery-orientation promoting new roles and
responsibilities for patients, for carers and for mental health professionals, will be presented and
discussed. Key messages - New rules, e.g. user involvement and recovery-orientation, as well as
new tools, e.g. shared decision making and psychiatric advance directives, have emerged. A
focus on collaborative models of care and individual choice confront all parties concerned with
an area of conflict between the concepts of empowerment and patient self-determination,
evidence-based medicine, and mental health legislation. Developments to meet these challenges
successfully must use the expertise of users and carers as well as professionals. Trialogue and
other forms of collaboration on equal footing have the potential to move the field beyond a
deficit model of mental illness towards a focus on the promotion of health, recovery and
resilience, and a broadening of treatment goals beyond symptom reduction and stabilization.
Cooperative and coordinated efforts including (ex-)users, carers, their spokespersons and public
health advocates offer chances to reduce stigma, discrimination and social exclusion, currently
seriously limiting clinical and other efforts towards recovery. The evidence-base in mental
health&nb sp;will be strengthened by valuing multiple perspectives as well as multiple methods
of research. Conclusions - The wisdom and energy of the user and carer movement in
collaboration with mental health professionals, who strive to overcome reductionistic and
uninspired conceptual frameworks, might just work in favour of substantial changes now.
Vocational Rehabilitation In Europe: Lessons From The Eqolise Trial
Tom Burns
University of Oxford, United Kingdom
The severely mentally ill invariably have low rates of employment despite extensive
rehabilitation efforts. Recently there has been a shift in vocational rehabilitation in mental health,
away from the more traditional structured rehabilitation programmes (often referred to as ‘trainand-place’) to more direct ‘place-and-train’ approaches. The most widely researched of these is
Independent Placement and Support (IPS) and several US RCTs have demonstrated very
significant advantages over high-quality traditional rehabilitation measured as obtaining openemployment. However we have learnt from bitter experience that complex community
interventions do not always work as well when translated to different social contexts and the
European employment situation is very different to that in the US. We conducted a multisite trial
of IPS in Europe which will be reviewed and its implications for our Mental Health Services
considered. The trial involved a random allocation of 50 psychotic subjects within each of six
European countries to either IPS or local standard vocational rehabilitation. Subjects were
followed up for 18 months by independent researchers. Primary outcome was obtaining open
employment and a series of secondary measures including duration of employment and social
and clinical outcomes. IPS was significantly more successful in all employment outcomes
including our primary outcome (obtaining employment (54% versus 27%. P<0.001)). The effect
size of IPS varied across the sites and demonstrates the importance of context in understanding
and predicting outcomes
„Soft coercion” in psychiatry
Bogdan de Barbaro
Departament of Familly Therapy, Chair of Psychiatry Jagiellonian University Kraków
Reflections on coercion in psychiatry usually pertain to involuntary hospitalisation or the use
of direct coercion on an agitated patient. It escapes our attention that psychiatric patients are
also subjects of verbal coercion, which consists in forcing the psychiatrist’s own view of
reality, based on medical knowledge, upon the patient. Indeed, this kind of coercion is ethically
justified (the patient regains health and stops suffering). However, the intrusion upon the
identity – a psychotic identity as well – is of a coercive nature, with its distinct negative results
for the patient and their family. To empirically illustrate the above argument a report on
research conducted at CM JU Adult Psychiatry Clinic in Kraków will be presented.
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SYMPOSIA
I. MENTAL HEALTH REFORM IN EUROPE
1.
Barriers and Opportunities for Reform in Central and Eastern Europe: Reflections from
the Mental Health Economics European Network
David McDaid1,2, Martin Knapp1,3, Helena Medeiros1 and the MHEEN Group
1
Personal Social Services Research Unit, London School of Economics and Political Science,
London, UK, 2European Observatory on Health Systems and Policies, London School of
Economics and Political Science, London, UK, 3Centre for the Economics of Mental Health,
Institute of Psychiatry, King’s College London, UK
Objective: As part of the two year 32 country EC supported Mental Health Economics European
Network (MHEEN), comparative information on barriers and opportunities to the reform of
mental health systems in central and eastern Europe, and the extent to which different economic
incentive mechanisms have and/or could be used to help to promote change, were
identified. Methods: Collation of information via a series of bespoke questionnaires, augmented
by a secondary rapid review of published and grey literature. Areas of analysis included
approaches to funding; exploration of the changing interfaces between health and other sectors,
such as social care, education and employment; and the role played by different economic levers
in system innovation and reshaping the balance of care. Results: The challenges faced in much
of central and eastern Europe are particularly acute: in contrast to the 'old' EU Member States: in
many countries little progress has been made in shifting the balance of care. Areas of the
workforce, essential to community based services, including social workers, also experience
shortages. Conclusions: Rigid financing mechanisms, a lack of flexibility in resource
allocation, an increased reliance on private health insurance and resistance to the closure of
isolated large scale long stay institutions in areas of economic derivation, are key factors
hindering the reform process. Where progress has been made, examples of innovative economic
levers can be identifi ed. Mechanisms which can help promote change and facilitate mental
health reform include transitional additional parallel funding for new and existing services,
economic regeneration packages in areas served by long-stay institutions and mechanisms which
link funds to service users regardless of where the service is delivered.
2.
Psychiatric Reform In Romania From An Eu And A Romanian Perspective
Katschnig Heinz1, Mugur Ciumageanu2, Dan Ghenea2, Raluca Sfetcu2
1
Ludwig Boltzmann Institute, Department of Social Psychiatry Vienna, 2National Centre for
Mental Health, Bucuresti, Romania
Objectives: During the accession process of Romania to the European Union the psychiatric care
system was evaluated by international organizations, showing that the system was mainly
hospital oriented and dominated by a medical model. Furthermore several human rights issues
proved to be critical. Mental health reform was seen as urgent and a number of activities were
initiated, including legal reform, by the Romanian government. Methods: In autumn 2006 the
National Centre for Mental Health was founded in Bucharest, and in December 2007 a so called
‘Twinning Project’, financed by the European Commission for two years commenced, with
experts from Austria, the Netherlands and Italy, and the main objectives of training hospital staff,
community mental health teams and general practitioners. The project also has an anti-stigma
component and the task of analyzing the legal and financing sit uation of the mental health care
12
system. Results: Since its start in autumn 2006, the National Centre for Mental Health has been
carrying out a variety of programs in the whole country. It assessed the situation and initiated a
number of reform related projects, such as improving the quality of hospital care, setting up
community mental health teams, designing and implementing training curricula for staff. Into
these activities the objectives of the twinning project fit well in. As expected, change is slow, but
staff working in the mental health field is receptive and enthusiastic about the possibilities of
reform. We shall report on the working methods and first experiences of the National Centre for
Mental Health and of the Twinning Project, focusing on difficulties and opportunities in view of
the huge task of carrying out mental health care reform for a large country, where mental health
care had been neglected for many decades. Conclusions: Romania, together with EU support,
has started a country wide psychiatric reform project, of which the encouraging first step will be
described.
3.
Mental Health Program In Poland - The Important Step To The Implementation Of The
European Psychiatry Values.
Katarzyna Prot, Jacek Wciórka
Institute of Psychiatry and Neurology, Warsaw, Poland
If we agree that the main European values are liberte, egalite and fraternite we can think how to
translate them to the psychiatric system.Liberte – means liberalization from asylum,
deinstitutionalization, transformation from hospital-based to community-based psychiatry
Fraternite – means de-stigmatization of the psychiatric patients and psychiatric treatment Egalite
- means equal access to the social goods – treatment, work, accommodation, assured by society
for the mentally ill like for many other its vulnerable groups.The predominant model of
psychiatric care in Poland is still hospital centered with coexisting ambulatory care, but without
active, community care. There is the lack of specially adapted working places, a small amount of
protective accommodation. The psychiatric treatment, psychiatric users and their families carry
the heavy burden of stigmatization. Mental Health Act (1994) introduces the community care as
one of the primary tools of treatment. The lack of financing caused the actual situation in which
the main goals of the Program wasn't realized. The new version of the Mental Health Program
was formulated in 2006. According to the Program the community system would be built on the
bases of community mental health centres, the number of beds in large hospitals would be
decrease. The main idea is to change the actual model of treatment in which the main resources
are concentrated in the institutions. The psychiatric reform is planed as a community reform but
also self-government reform (coordination of the different form of psychiatric care and
treatment on the local level). Our hope is that the growing understanding in Polish society
regarding psychiatric patient's problems and the European obligations of Polish authorities will
facilitate the reform.
4.
Surviving Without The Asylums Is Possible, But Not Enough. Old And New Walls In
Community Psychiatry
Giuseppe Tibaldi
Centro Studie Ricerche in Psichiatria, Torino
Italy Objective There is a growing need to identify key factors which allowed for a radical
transition towards a community psychiatry without asylums as well as for its survival in the long
term. Methods Assessment of the levels of variability emerging from National surveys in the last
decade, and analysis of the Italian debate about mental health issues within, and outside, the
professionals’ field Results Ubiquitous ability to survive without any asylum, but high variability
in the development of the network of local community services. Low levels of hospital and
13
community beds. Cultural acceptation of the mental health users’ rights, above all the refusal of
lifelong mental institutions. All professionals agreed on the issue of “social recovery” (to be
considered as a civil right): in this perspective, good practice and good outcome coincide with
the new scenario, without mental hospitals: Most of the current debate is more concentrated on
organizational issues than devoted to test, or adopt, the best practices aimed at “individual
recovery” Conclusions Political and cultural pressures are always more relevant in generating or
supporting change, as at the beginning. Coercion and lack of a true long term investment on
users’ abilities are the current shadows of the old asylums (old walls). Fragmentation among
services as well as among specific professional perspectives as new risk factors for community
psychiatry (internal new walls). The link between crimes and mental disorders, highly supported
by the media, as the main promoter of the stigma about dangerousness (external new wall).
5.
Accessibility And Utilisation Of Mental Health Care Services
Grazia Z., Donisi V., Secco G., Battaglia G., Grigoletti L., Tansella M., Amaddeo F.
Section of Psychiatry and Clinical Psychology, Department of Medicine and Public Health,
University of Verona, Italy Department of Geography, University of Padova, Italy
Objective: Health care systems should be able to guarantee equal accessibility to citizens for
ensuring that people receive care they need, when and where they need it. Accessibility is the
result of the interaction between different components: services’, patients’ and environment
characteristics and distances. In this study, a model of the spatial accessibility to mental health
services, for people with mental illness, has been developed. Methods: The study has been
conducted in the Verona Community-based Mental Health Service, in Northern Italy (450,000
inhabitants). All patients who have had at least one contact with psychiatric services during
2001-2006 and received an ICD-10 diagnosis have been included (7,000). The model has been
divided in two parts. The first rates the services’ capacity to provide mental health care using the
scores of the European Service Mapping Schedule and of the International Classification of
Mental Health Care. The second assesses the spatial interaction between patients and services
using a potential accessibility model; where the services’ capacity varies according to patients’
characteristics, and the patients’ mobility behaviours is modelled using an inverse logistic
function of the distance taking into account the road and public transport network. Results: An
“accessibility-index” has been calculated for each patient to assess how and where different
levels of accessibility influence the use of health services. Results show that the accessibility,
measured taking into account all the components, improve the treated prevalence and the
utilisation of services. Conclusions: Health geography approach demonstrated to be particularly
informative when applied in the field of mental health services evaluation
II. FORMAL AND INFORMAL COERCION
1.
Paternalism in Mental Health: Time for Reappraisal
Tom Burns
Department of Psychiatry, University of Oxford, OX3 7JX, United Kingdom
Objective: Paternalism is considered an outmoded and discredited concept in modern mental
health care. Most modern policy and legislation negotiations consider patient autonomy to be the
dominant ethical dimension despite the historical centrality of beneficence or paternalism. This
paper explores whether there is support for forms of paternalism in other areas of ethical
discourse. Method: Isaiah Berlin’s distinction between positive and negative liberty is taken as a
starting point to explore current thinking about paternalism in political, economic and feminist
14
discourse. Results: Political theories acknowledge the competing merits of several moral forces
(Liberté, Egalité, Fraternité). Amartya Sen has proposed the need for ‘circumscribed
congruence’ to accommodate them to promote social justice. Economists talk of th e role of ‘Soft
Paternalism’ in the management of complex welfare systems such as the substitution of ‘opt out’
for ‘opt in’ pension schemes. (Similar proposals are current for organ donation.) In his economic
proposals for Africa, the economist Jeffrey Sachs declares ‘free market economics are passé’.
The strongest critique comes from Feminist thinkers and particularly from the ‘ethics of care’
group who stress the centrality of relationships and the positive moral virtue of partiality. They
argue that traditional, male dominated, ethics privilege quasi-legal terminology and impartial
principles whereas women build ethical principles from the experience of important, close
relationships and obligations. Conclusions: Psychiatry has, undoubtedly, been guilty of
unwarranted paternalism in the past. However this does not mean that careful consideration of its
appropriate place in modern care has no place in modern care. The pervasive belief in mental
health that paternalism has no legitimacy in other areas of ethical discourse is unfounded.
1.
Community Treatment Orders: Challenges in Conducting an RCT
Ksenija Yeeles, Tom Burns and the ULTIMA team Department of Psychiatry
University of Oxford, OX3 7JX, United Kingdom
Objectives: There is extensive international experience of different forms of compulsory
treatment for individuals with severe mental illness (SMI) outside hospital but only limited
scientific support. With its introduction in the UK in 2008 there is a call for stronger evidence.
The ULTIMA team is funded to conduct an RCT but this faces major ethical and practical
problems. We outline our approach to these challenges. Methods: We i) identified the likely
ethical, legal and practical opposition ii) decided on a feasible and acceptable point of
randomization and appropriate outcome measures iii) contacted clinical services and
professionals who will be using the provision and explor ed how to engage their cooperation in
the study. Results: There is a limited, but important, range of agencies whose collaboration is
crucial for such a study. There are precedents for randomization of legal interventions and these
are drawn on for ‘building social capital’ with these agencies for the study. There is surprisingly
good consensus among clinicians on the point of randomization and the important outcomes. The
conflicting benefits of a wide or targeted sampling strategy remain unresolved and require
further discussion. The essential need to construe the study so that genuine equipoise is
addressed has emerged as the dominant challenge. Conclusions: A successful RCT of CTOs is
still needed. However it needs to be formulated as a trial of differing forms of community
coercion rather than ‘CTO vs Control’. This reframing is essential both to defend against legal
challenges and to establish adequate clinical equipoise.
2.
What is the Nature and Extent Of Informal Coercion (Ic) in Mental Health Care?
Kathryn Davies, Helen Nightingale and Tom Burns for the ULTIMA team Department of
Psychiatry
University of Oxford, United Kingdom
Objectives: Studies of Coercion have traditionally used legal status as the distinction between
coerced and non-coerced patients. However the MacArthur study in the US indicated that up to
half of public mental health patients had experienced IC (‘leverage’). We wished to establish if
this was so in the UK, how it might vary between different clinical groups, and how they viewed
it. Methods: We are conducting structured interviews with 100 outpatients in four clinical
situations – i) methadone clinic attenders, ii) psychosis patients in assertive outreach, iii)
psychosis patients in CMHTs, iv) non-psychosis patients in CMHTs. We are collecting
15
information on the exten t of IC, its relationship to service setting and patient characteristics.
Results: Levels of IC are high in the early sample, equivalent to those in the US study. There are
emerging differences between the four clinical groups which will be presented. Conclusions:
Informal coercion appears to common in UK mental health practice. There appears to be more
variation in the forms used than the overall level between clinical groups. A greater
understanding of its extent, responses to it and its effects are needed to improve training and
practice.
3.
Care Contacts Of Individuals Seen By The Police For Mental Health Crises
Rob van den Brink1 Jan Broer2 Fons Tholen1 Wim Winthorst1 Durk Wiersma1
1
University Medical Center Groningen, 2Municipal Health Authority Groningen. Groningen, the
Netherlands
Objective: In many countries the police have a statutory obligation to help individuals who
experience a mental health crisis, and who are not able to obtain the necessary help them selves.
Unclear is, what kind of mental health problems are seen by the police, and whether the
problems led to a crisis because the individuals were out of contact with the mental health
services. Furthermore, it is unknown how the police handle the crises, and whether this has any
effect on the contacts with the mental health services. Methods: All calls to the police for mental
health crises, registered in a local police database during one year, were studied. Police handling
was assessed from the report entered by the police officer involved. Information on psychiatric
diagnosis and care contacts with the mental health services was obtained from a regional mental
health register. Results: During one year 492 calls upon the police for mental health problems
were registered (2.5 per 1000 inhabitants). Half of the calls were dealt with by the police
themselves, in 36% the police directly contacted the mental health services, and in 14% the
individual was taken to the police station for assessment by a physician. Eighty percent of the
calls concerned a person known to the mental health register. Conclusions: Analyses now
concentrate on the number and nature of care contacts in the year prior to, and month after the
crisis. It will be reportered to what extend contact with the mental health services was
(re)established after the crisis, and whether this depended on the way the police handled the
crisis.
4.
The core characteristics and nursing care activities in psychiatric intensive care units in
Sweden.
Martin Salzmann-Erikson1, Kim Lützén2, Ann-Britt Ivarsson3, Henrik Eriksson4
1
School of Health and Social Sciences, Högskolan Dalarna, Sweden. Department of Health
Sciences, Örebro University. 2School of Health and Social Sciences, Högskolan Dalarna,
Sweden. 3Department of Health Sciences. Örebro University, Sweden. 4Department of Caring
and Public Health Sciences. Mälardalens University, Eskilstuna, Sweden
Objective: Internationally, research on psychiatric intensive care units (PICU) commonly
reports results from demographic studies such as criteria for admission, need for involuntary
treatment, and the occurrence of violent behaviour. A few international studies describe the
caring aspect of the PICU based specifically on caregivers’ experiences. The concept of PICU in
Sweden is not clearly defined. The aim of this study is to describe the core characteristics of a
PICU in Sweden and to describe the care activities provided for patients admitted to the PICU.
Methods: Critical incident technique was used as the research method. Eighteen caregivers at a
PICU participated in the study by completing a semi-structured questionnaire. In-depth
interviews with three nurses and two assistant nurses also constitute the data. Results: An
analysis of the content identified four categories that characterise the core of PICU: the dramatic
16
admission, protests and refusal of treatment, escalating behaviours and temporarily coercive
measure. Care activities for PICU were also analysed and identified as controlling – establishing
boundaries, protecting – warding off, supporting – giving intensive assistance and structuring the
environment. Conclusions: Finally, the discussion put focus on determining the intensive aspect
of psychiatric care which has not been done in a Swedish perspective before. PICU were
interpreted as a level of care as it is composed by limited structures and closeness in care.
5.
Care for Mentally Disordered Persons in the European Prison Systems – the EUPRIS
Study
Hans Joachim Salize & Harald Dressing
Central Institute of Mental Health, Mannheim, Germany
Among the more than 9.25 million people currently being held in penal institutions worldwide,
mentally disordered inmates constitute a serious problem. Despite the standard doctrine in most
countries that mentally ill offenders lacking criminal responsibility are not to be punished but
referred to and detained in forensic psychiatric facilities for specialised care, the prevalence of
psychiatric morbidity among prisoners by far exceeds the rate of mental disorders in the general
population. However, international research on this issue is limited. To bridge this gap, the
European Commission has recently funded a study for exploring the overall concepts and
capacities of mental health care provision in prisons and collecting prevalence and other data
from 25 European countries. Hindered by very bad health reporting standards, the study revealed
deficient mental state screening and assessment procedures at prison entry as well as during the
term or prior to release across Europe, that prevent the implementation of adequate primary,
secondary or tertiary prevention programmes for the mental disorders most prevalent in prisons
and increase the risk of relapsing and re-offending for released prisoners. None of the included
countries provides regular national statistics on the frequency of mental disorders of prisoners or
on the availability or frequency of psychiatric treatments. Together with a mostly unknown
amount of NHS-inclusion into prison mental health care, missing structure or outcome data
currently prevents the identification of a favourable concept of prison mental health care across
Europe. The paper presents the available data collected during the study as well as the suggested
set of standardized indicators whose implementation would enable to evaluate this seriously
neglected field.
III. OUTCOME MANAGEMENT AND THERAPEUTIC RELATIONSHIP IN MENTAL
HEALTH CARE
1.
Effects Of Structured Communication In Community Mental Health Care - More Findings
From The Mecca Study
Stefan Priebe
Unit for Social & Community Psychiatry, Barts & The London School of Medicine, Queen
Mary, University of London and the MECCA study group
Objectives. The MECCA study has shown that computer mediated structuring of the routine
communication between key-worker and patient (the DIALOG intervention) can improve one
year outcomes in community mental health care. Whilst the general results have already been
published (Priebe et al, BJPsych, 2007) more detailed findings on subgroups and the role of the
therapeuitc relationship ill be presented here. Methods. Further analysis of the MECCA data
including videotapes of key-worker patient sessions usin the DIALOG intervention. Results. The
effect intervention of the intervention varies substantially between subgroups at different sites
17
and/or with different baseline scores. The quality of the therapeutic relationship predicts outcome
across the intervention and control group. The way the intervention was applied in practice
showed great variation. Conclusions. Further research should focus on defined subgroups and
further refine the intervention.
2.
The therapeutic relationship in a multicenter RCT on needs-oriented discharge planning
for high utilisers of psychiatric services
Sabine Steffen1, Thomas Becker1, Wolfgang Gaebel2, Harald Freyberger3, Helmfried E.
Klein4, Tilman Steinert5, Bernd Puschner1
Ulm University, Department of Psychiatry II2 Düsseldorf University, Department of Psychiatry
and Psychotherapy3 Greifswald University, Dept. of Psychiatry and Psychotherapy at Stralsund4
Regensburg University, Dept. of Psychiatry and Psychotherapy5 Ulm University, Dept. of
Psychiatry and Psychotherapy I
Objective: To examine the role of the therapeutic relationship in the treatment of high utilisers
of psychiatric care. Methods: The multi-center randomised trial "Effectiveness and costeffectiveness of needs-oriented discharge planning and monitoring for high utilisers of
psychiatric services" started in January 06. Recruitment of 498 participants among patients
receiving inpatient psychiatric treatment in five psychiatric university hospitals in Germany has
been completed in July 07. At baseline (discharge from impatient treatment), patients and
clinicians rated the quality of the therapeutic relationship on the German adaptation of the STAR
(STAR-P and STAR-C). Furthermor e, a range of standardised outcome assessments tapping into
symptomatic impairment, quality of life, and needs were obtained from patients, clinicians, and
independent raters. Results: Severely impaired psychiatric inpatients and their clinicians were
willing and able to provide reliable information on the quality of their therapeutic relationship.
Results on complementarity and differences in ratings of the therapeutic relationship from
different perspectives (patients vs. clinicians) will be reported. These will be added by findings
on predictors of its initial quality from characteristics of patients (severity of impairment, illness
history, diagnosis) and clinicians (professional background, experience). Conclusions:
Focussing on the quality of the therapeutic relationship, implications of these results for
improving the quality of mental health care for high utilisers of psychiatric services will be
discussed.
3.
The impact of mental illness on patient satisfaction with the therapeutic relationship –
a multilevel analysis
Johan Håkon Bjørngaard
Sweden
Background: The relationship between patients and their clinicians is an essential factor in
psychiatric treatment. The purpose of this study was to analyze the influence of psychopathology
on patient satisfaction with the therapeutic relationship. Methods: Data from 969 patients from
40 different treatment teams collected from eight Norwegian community mental health centres
were analyzed. Patient satisfaction with the therapeutic relationship was assessed with a six-item
scale: sufficient time for contact/dialogue, clinicians’ ability to listen and understand, follow-up
of planned interventions, respect for patients’ views/opinions, cooperation among clinicians, and
patients’ influence on treatment. Mental illness was assessed using the Health of the Nation
Outcome Scales (HoNOS) and Global Assessment of Functioning (GAF) scale. Diagnoses were
established using the International Statistical Classification of Diseases and Related Health
Problems – 10th revision (ICD-10). Treatment outcomes were clinically assessed retrospectively
by rating changes from start of treatment on seven items. Multilevel regression analysis was used
18
for a simultaneous analysis of the contribution of patient and team variables. Results:
Satisfaction was associated with treatment outcome, better health as assessed using HoNOS,
being female, of older age and having less psychiatric team severity indicated by the teams’
mean GAF score. Patients with a schizophrenia spectrum disorder were more satisfied when
treated as in- and day patients, compared with outpatient treatment. Patients in other diagnostic
categories were less satisfied with day treatment. Conclusions: Patients’ perceptions of the
therapeutic relationship may be influenced by psychopathology. Teams comprising many
patients with severe mental illness may constrain the therapeutic relationship. Hence, resources
and organizational measures should be carefully considered in such care units.
4.
Short and mid-term effectiveness of outcome management in people with severe mental
illness
Bernd Puschner, Carina Knaup, Dorothea Schöfer, Thomas Becker
Ulm University, Department of Psychiatry II
Objective: To provide evidence on the short- and mid-term effectiveness of feedback of
outcome to patients with severe mental illness and their clinicians in inpatient psychiatric care.
Methods: The cluster-randomised trial "Outcome monitoring and management in inpatient
psychiatric care" (EMM) took place from June 2005 - November 2007 at a large psychiatric
hospital in rural Bavaria. 294 participants were asked to provide information on treatment
outcome via weekly computerised assessments. Patients and clinicians in the intervention group
received continuous feedback of outcome. Primary endpoints were short- (at discharge) and midterm (at 6-month follow-up) effectiveness of feedback of outcome. Results: At discharge, there
were no differences between the feedback and no-feedback groups on patient-rated outcome.
However, feedback of outcome contributed to adaptive allocation of resources via reducing
length of stay in patients with good treatment success. Further findings on the mid-term effect of
the intervention based upon independent HoNOS-ratings will be presented. Conclusions:
Discussion will focus on the implications of these findings for improving outcome management
and structuring patient-clincian-communication in mental health care.
5.
The role of patient’s and therapist’s personality traits in the long-term psychotherapy of
patients with diagnosis of schizophrenia
Igor Hanuszkiewicz, Maria Wojnar, Andrzej Cechnicki
Community Psychiatry Unit, Chair of Psychiatry, Jagiellonian University, Schizophrenia
research Group, Kraków
Objective: The purpose of the presented study was to evaluate what importance the basic
dimensions of personality of therapists and patients have for the character of therapeutic relation.
Subjects and Methods: The study group consisted of 33 patients with schizophrenia (ICD 10);
17/16 F/M, mean age 29.2 yr. 11 therapists (7/3 F/M, mean age 37.4.) remaining in therapeutic
relationship with these patients, were assessed. The therapists had many years of practice,
worked in a community therapy and rehabilitation network. The assessments were conducted in
the context of therapies which had lasted for at least 6 months. To evaluate relationships the
Dyadic Therapist-Patient Relationship Questionnaire was used in its Polish version (Cechnicki,
Wojnar 1997). It consists of two separate questionnaires, and enables assessment in the
dimensions of: acceptance, professionalism, insecurity, domination, rejection. Personality was
assessed with the 60-item NEO-FFI questionnaire by Costa and Mcrae in 5 personality
dimensions. In analysis of the results the methods of variable correlation and step regression
were used. Results: The level of extraversion of the therapists correlated with all dimensions of
the relation and with level of rejection indicated by the patients. Patients felt less rejected if their
19
therapist had higher level of openness which was also correlated with a lesser feeling of
uncertainty on the side of the therapist. A lower level of neuroticism in patients was correlated
with a lower level of uncertainty of therapists. A higher level of conscientiousness in the patient
was correlated with a tendency to see the therapist as more assured and less rejecting in the
therapy process. Conclusion: The research showed that in individual psychotherapy some
personality traits of therapists and patients may influence in a very specific way the
“atmosphere” of a therapeutic relation. Important factors on the side of the therapist included
extraversion and openness and on the side of the patient - neuroticism and conscientiousness.
The results may be regarded as a hint for planning the goals of personal training for therapists
and for the role of personality assessment in the psychotherapy.
IV. STIGMA AND MENTAL ILLNESS
1.
Which Barriers do Persons With Psychosis Perceive in Their Everyday Life? A Survey On
Experienced and Anticipated Discrimination In First-Episode Psychosis.
Lasalvia A., Bertani M., Bissoli S., Bonetto C., Cristofalo D., De Santi K., Lazzarotto L.,
Marrella G., Mazzoncini R., Tosato S., Tansella M. & Ruggeri M. on behalf of the PICOSVeneto Group
Department of Medicine and Public Health, Section of Psychiatry and Clinical Psychology,
University of Verona, Italy
Objective: Most research on stigma and discrimination associated with mental illness focused on
what attitude the general population has towards psychiatric patients. Few studies have been
conducted so far on self-reported stigma in people with mental illness and very few explored the
perception of patients experiencing first-episode psychosis. This survey aims to describe patterns
and severit y of 1) experienced and 2) anticipated discrimination reported by people with firstepisode psychosis. Methods: Cross-sectional survey conducted within the context of the
Psychosis Incident Cohort Outcome Study (PICOS), a large multisite research taking place in the
Veneto Region (Italy), aiming to characterise patients experiencing their first episode of
psychosis and to develop a comprehensive predictive model of outcome, by integrating clinical,
social, genetic and MRI data. Experience and anticipated discrimination were assessed through
face-to-face interviews in a sub-sample of 50 psychotic patients one year after illness onset,
using the Italian version of Discrimination and Stigma Scale (DISC-11). This is a standardized
scale which explores whether participants experienced discrimination because of their mental
illness in a series of key areas of everyday life and social participation, including work, marriage,
parenting, housing, leisure, and religious activities; the scale also considers how far participants
limit their own involvement in important aspects of everyday life. Results: 50 psychotic patients
(mean age: 34.1, sd 9.2; male: 65%) were interviewed. The most frequently occurring areas of
experienced discrimination were: discrimination by family members (43.4%), keeping a job
(30.4%); finding a job (30.4%), intimate or sexual relationships (30.4%) and making or keeping
fr iends (21.7%). Anticipated discrimination was common in the following domains: looking for
a close relationship (52.2%), applying for work or training or education (43.5%). Moreover 60%
felt the need to conceal the diagnosis and 43.% felt that other people avoided or shunned
them.Conclusions: Persons with psychosis tend to perceive experiences of discrimination and
anticipate discrimination in a series of key-areas of every-day life in the very beginning of their
illness course. This suggests the need for mental health services to develop specific and early
strategies aiming to enhance patients’ self-esteem and promote their full social integration.
20
2.
Beliefs of discrimination and rejection experiences among people with schizophrenia living
in the community. Results from the dialog study.
Lars Hansson, Tommy Björkman, Bengt Svensson and the DIALOG group
Department of Health Sciences, Lund University, Sweden
Objective: The DIALOG study is a trial investigating the effectiveness of a new computermediated intervention structuring the patient-key worker dialogue, focusing on patients’ quality
of life, needs for care and satisfaction with treatment. As part of this study, patients’ perceptions
of stigma in terms of discrimination and experiences of rejection were also investigated. The aim
of this part of the study is to elucidate the occurrence of stigma and clinical and social
characteristics associated with stigmatising beliefs and experiences. Methods: In a cluster
randomised controlled trial, 134 key workers in six countries were allocated to DIALOG or
treatment as usual; 507 people with schizophrenia or related disorders were included. A 12
month follow-up was performed. Primary outcome was subjective quality of life; secondary
outcomes were unmet needs and treatm ent satisfaction. Among other areas, assessments of
symptoms, stigma and empowerment were also included. Results: There were no significant
changes in perceptions of rejection or discrimination during the follow-up and no effect of the
DIALOG intervention on perceptions of stigma. The most prominent beliefs of discrimination
included that job applications would be turned down and that people think less of people with a
mental illness. More beliefs of discrimination were both at baseline and follow-up primarily
associated to a lower level of empowerment. Most frequent experiences of rejection were to be
treated differently and that people are avoiding you. More rejection experiences were both at
baseline and follow-up primarily related to a worse subjective quality of life. Conclusions:
Perceptions of discrimination and experiences of rejection were common. The negative
relationship between stigma and quality of life and empowerment indicates that the development
of interventions targeting stigma have a high priority in community-based mental health
services.
3.
Perceptions of social inclusion: a mixed methods study of people with high support needs
Liz Chisholm1, Justine Schneider2, Janet Betinis3, Angela Smith and Torsten Shaw3, Paul
Leighton,4 Philip Houghton5, Anne Felton6
1
Framework Housing Association, Nottingham 2Institute of Mental Health, Nottingham
3
Making Waves, Nottingham 4Trent R&D Support Unit, University of Nottingham,
5
Nottinghamshire Healthcare NHS Trust 6University of Nottingham
Background The study was developed by service users, professionals and researchers with a
shared interest in the concept of ‘social capital’. Little is known about the social capital of people
who have spent much of their lives receiving mental health care. We expected to find variations
in social capital in different neighbourhoods, where people were more or less integrated with the
local community. Objective The aim was to investigate service users’ perceptions of aspects of
social capital, and to find out about their sources of practical support. Methods A semistructured questionnaire was developed by the study team. Service users then interviewed 20
people with long term mental health problems living 'in the community' in three different
settings. The interviews were recorded, transcribed and analysed by members of the team. A
structured questionnaire – the UK Resource Indicator (Webber and Huxley, 2007) was also used.
Results Four key themes emerged: relationships, aspirations, barriers, and community. Mental
health services had an impact upon participants’ experiences within each thematic area.
Although relationships with support staff were good, participants seldom engaged with the wider
21
community and so had low soci al capital. They aspired to roles beyond that of ‘service user’ but
were held back by fear of victimisation and experiences of stigma from the local community.
Conclusions The social capital of service users is low, and made worse by fear and
discrimination surrounding mental ill health. This frustrates their aspirations and mars users’
experiences of community life.
4.
Stigma Experiences Among Persons With Mental Illness: Relationships To Social Network,
Self-Related Variables And Clinical Characteristics
Bertil Lundberg, Tommy Björkman
Objective: The most research on stigma and mental illness has focused on describing the results
of attitude surveys or relating to the portrayals of mental illness by the media. In this study, the
cross-sectional relationship between reported actual stigma and measures of social network,
self-related and clinical variables was examined. Methods: A cross-sectional study assessing
actual rejection experiences, clinical characteristics, social network and self-related variables
was performed among 200 mental health consumers. Results: The main findings showed that a
higher degree of rejection experiences were associated with a worse psychosocial function,
smaller social network, low self-esteem and sense of coherence. Conclusions: Stigma
experiences showed a significant association with multiple clinical factors, social network and
self-related variables. In order to further elucidate stigma and its consequences for the afflicted,
studies with a qualitative design are suggested.
5.
The Gamian-Europe Stigma Study: An International Perspective On The Experience Of
Self-Stigma
E.Brohan1, R. Elgie2, N. Sartorius3 & G. Thornicroft1
1
Health Service and Population Research Department, Institute of Psychiatry, King’s College
London, England 2GAMIAN-Europe Riverside Business Centre, River Lawn Road, Kent;
England 314 Chemin Colladon, 1209 Geneva, Switzerland.
Objective: The primary objective of this study was to collect European data on the nature and
frequency of self-stigma experienced by people with a diagnosis of mental illness. Secondary
objectives include identifying the proportion of reported discrimination and empowerment, as
well as investigating the relationship between self-stigma, empowerment, perceived
discrimination and socio-demographic factors. This presenation will introduce initial results as
well as a discussion of the challenges involved in conducting a large international survey.
Methods: The study had a cross-sectional design where participants were asked to complete a
postal survey measuring their reported levels of self-stigma, empowerment and perceived
devaluation and discrimination. Data were collected from members of GAMIAN-Europe mental
health charity organisations within 20 countries in geographical Europe. In countries where
English is not the primary language, a consistent translation and cross-cultural adaptation
procedure was adopted to ensure that the survey packs used in each country were as comparable
as possible. This presentation considers the responses of the participants with a diagnosis of
schizophrenia or other psychotic disorders. Results: A total of 1,338 surveys were included.
Data anaysis focused on establishing international differences in levels of self-stigma. As well as
examining the the influence of perceived devaluation & discrimination, empowerment and sociodemographic factors on this variable.Conclusions: This research presents a comprehensive
picture of self-stigma, as reported by individuals with a diagnosis of diagnosis of schizophrenia
or other psychotic disorders within Europe.
22
6.
Stigma and Client Satisfaction in Mental Health Services
Verhaeghe Mieke, Bracke P., Christiaens W.
Department of Sociology, Ghent University
Objective: Numerous studies have revealed that stigmatization of persons with mental health
problems can bring about a large array of negative consequences. One outcome that has been
largely neglected is client satisfaction. In this empirical study the link between stigmatization
and client satisfaction is explored, and compared with the association with life satisfaction.
Furthermore, the role with the self-concept is examined. Methods: Survey data from a sample of
clients (N = 741) of 36 professional mental health services in Belgium are used to explore these
relationships, while controlling for client background characteristics. Three dimensions of stigma
experiences are studied: stigma expectations, social rejection and self-rejection. Results: The
results reveal that the associations depend on the dimension of stigma under study. Whereas only
stigma expectations and concrete social rejection experiences are directly linked with life
satisfaction, only self-rejection is directly linked with client satisfaction. These relationships are
not explained by the self-concept. Conclusions: The findings suggest that stigma has not only
negative consequences for outcomes referring to the general quality of life, but also for outcomes
that point more directly at the immediate treatment context. They are in line with recent studies
revealing the adverse effects of stigma in the treatment process, leading to the conclusion that
stigma could be considered as a negative side-effect reducing effectiveness of mental health
services. The differential findings also stress the importance of studying multiple dimensions of
stigma experiences, as well as multiple outcomes.
V. OCCUPATIONAL THERAPY AND WORK
1.
Profiles of occupational engagement in people wit Schizophrenia, poes: a new measure of
time use
Ulrika Bejerholm U.,Hansson, L., & Eklund, M.
Department of Health Sciences, Medical Faculty, Lund University, Sweden
Objective: This study describes the development and psychometric testing of a new instrument,
The POES. Methods: The development concerned the construction of the POES and content
validity, internal consistency and inter-reliability. The construct validity was also tested by
investigating the relationships between POES and measures of psychosocial functioning and
well-being. The POES consists of three parts. Part I involves the data collection, in terms of the
client’s completion of one or more 24-hour time-use diaries. Part II constitutes the rater’s
assessment of level of occupational engagement, based on nine items rated on a four-point scale.
Part III concerns assessment of whether the current lifestyle involves over-stimulation, understimulation or a balance regarding the fit between personal abilities, the constituents of the
environment and activity challenge. Results: For Part II, the mean weighted kappa was .70.
Internal consistency was satisfactory, alpha=.95. Construct validity was assessed in relation to
psychosocial functioning (rs=.73), activity level (rs=.70), and satisfaction with daily occupations
(rs=.50). Moreover, participants’ scores of SOC, LOC, Mastery and a composite score of quality
of life increased with increasing level of occupational engagement, while the level of
psychopathology decreased. In Part III , the mean kappa value for the three items was .78.
Conclusion: This study provided initial support for content validity, inter-rater agreement,
internal consistency and construct validity of the POES, which may serve as a valuable measure
23
that helps to assess the level of engagement and whether the current lifestyle promotes health and
well-being.However, further research on clinical utility is warranted.
2.
Avoiding under recruitment: lessons learned from AN RCT
Louise Howard, Heslin, M, Thornicroft, G, de Salis, I, Tomlin, Z, Donovan, J.
Health Service and Population Research Department, Institute of Psychiatry, King’s College
London
Objective: Under-recruitment to randomised controlled trials (RCTs) is often problematic and
there may be particular difficulties in recruiting patients with severe mental illness. This study
aimed to establish whether and why there is under-recruiting of patients with severe mental
illness in an RCT of supported employment (the Supported Work and Needs – SWAN - study).
Methods: Qualitative study during the recruitment phase of an RCT of supported employment.
Trial staff and recruiting clinicians were interviewed. Data were analyzed thematically using
constant comparative techniques. Results: Recruitment rates were low. Reasons for recruitment
difficulties will be presented and include paternalism, lack of understanding of the concept of
randomisation and a lack of equipoise. Conclusion: Reasons for recruitment difficulties in trials
involving patients with severe mental illness include issues that occur in trials in general, but
others are more specific to these patients. Clinician and patient involvement in the study design
may improve recruitment in future similar trials.
3.
The SWAN (Supported Work and Needs) Study: AN RCT of Supported Employment
Margaret Heslin Howard, L, Rice, C, Leese, M, Jarrett, M, McCrone, P, Spokes, T,
Thornicroft, G.
Health Services and Population Research Dept; Institute of Psychiatry, King’s College London
Objective: International trials of supported employment have consistently reported significant
increases in rates of competitive employment in patients randomised to high fidelity supported
employment programmes. There have been no large RCTs of supported employment in England.
This study aimed to assess the effectiveness of the Individual Placement and Support (IPS)
model of employment in the UK. Methods: Study design: RCT. Study population: Participants
receiving community psychiatric care with a diagnosis of severe mental illness (duration of
illness over 2 years), aged 18-65 and unemployed for at least 3 months before enrolment into the
study. Study arms: Participants were randomly allocated to either supported employment
intervention or the treatment as usual control group. Follow-up assessment: Participants were
followed up at 1 year by a research worker who was blind to allocation status employment status,
and service use, and various measures of psychosocial functioning were assessed. Results: 219
participants were recruited. 147 (67%) of participants were male. The mean age of participants
was 38 (9.4 s.d) years old. 90% of participants were followed up in both arms at 1 year follow
up. Conclusions: This presentation will compare the results found in this study with those found
in previous studies and explore reasons for differences in outcomes.
4.
Day-Care centres for people with sMI – an intervention project
Mona Eklund
Mona Eklund, Dep. Of Clinical Neurosciences, Division of occupational Therapy, Lund,
Objective: This project addresses the possibility for people with severe mental illness (SMI) to
lead an active daily life with meaningful daily occupations, including work, home chores, leisure
activities, and social activities. The project has different phases, the first of which aims at
24
evaluating existing day-care centres (DCC) in comparison with no structured daily occupation, in
terms of the visitors’ satisfaction with daily occupations, perceived status, motivation, wellness,
social interaction, etc. Methods: About 80 visitors at DCC and a comparison group of 80
individuals with no regular daily activity were included. The DCCs were categorised in two
groups, those who were work-oriented and those who mainly served as meeting places. The
analyses compared people visiting these two categories regarding the target variables, and also
the DCC group as a whole against the comparison group. So far, only preliminary results have
been obtained. Results (preliminary): No differences were found between the work-oriented
and the meeting place DCCs regarding satisfaction with daily occupations, perceived status, or
wellness. The motivational drives for visiting a DCC differed, however. Those who visited
work-oriented DCCs more often went there because they learnt something and because they
wanted better social status. Regarding differences between the DCC group as a whole and the
comparison group, the only significant one was that the DCC group was more active during the
day. Conclusions: The findings so far indicate that visiting a DCC was not associated with
better wellbeing or satisfaction in any respect, neither were there any substantial differences
between people visiting work-oriented and meeting place DCCs. However, variables such as the
social network, needs, and engagement in the DCC still remain to be analyzed, and results from
these might change the result picture.
5.
Adjuvant Occupational Therapy for Work-related Major Depression: Follow up of a
Randomized Controlled Trial including Economic Evaluation
A.H. Schene, M.J. Kikkert, J.A. Swinkels, M.W.J. Koeter, P. McCrone
Department of Psychiatry, Academic Medical Centre, Amsterdam,
Objective: Major depression has far-reaching consequences including impairment in work
functioning and absenteeism. Until recently employment status and the capacity to work was a
sorely neglected topic in depression literature. For those patients for whom depression is related
to impairment in occupational functioning, recovery may stagnate if ´work´ is not part of the
treatment plan. We determined - for the first time - the effectiveness of the addition of
occupational therapy to treatment as usual on recovery from depression, work resume, work
stress and costs. Method: Setting: Program for Mood Disorders, Academic Medical Center,
Amsterdam. Design: Randomized controlled trial. Follow up period: 42 months Participants:
62 adults with major depression and mean absenteeism of 242 days.
Interventions: Treatment as usual (TAU: outpatient psychiatric treatment) and TAU plus
occupational therapy (OT). Outcome measures: Assessments at baseline, 3, 6, 12 and 42
months. Outcome domains: depression, depression symptoms, work resume, work stress, and
costs. Results: Addition of OT to TAU did not improve depression outcome but resulted in a
significant reduction of work loss days during the first 18 months. Time between baseline and
the moment of any work resume showed a significant (p= .001) difference in favor of OT. OT
increased total mental health care costs, but overall showed an economic gain caused by greater
productivity. In this paper we will concentrate on follow up data over 36 months. Conclusion:
Results suggest that the addition of OT to TAU reduces absenteeism but not depression. OT
reduces total costs. The effect on work endures for a period of at least 12 months after the
intervention. The study further shows that the impact of depression on work is substantial.
25
VI.
COMMUNITY
ORGANIZATION
MENTAL
HEALTH
SERVICES:
PROBLEMS
AND
1.
The state and the implementation of evidence based methods
Mikael Sandlund1, Urban Markström2
1
Dept of Clinical Science/Psychiatry, 2Dept of Social Work, Umeå University, Sweden.
Objectives: To discuss the means and limits of governmental authorities’ abilities to make
services providers to practice evidence based methods in the service for persons with psychiatric
disabilities. The examples are drawn from Sweden, a nation where services mainly are parts of
the public sector. Methods: The presentation is based on several years of experiences from
health systems research and assignments as experts in governmental committees to develop
services within the psychiatric field. Results: The mission to implement “new methods” in the
practice of social and psychiatric services is difficult, in fact much more cumbersome as it may
seem at first glance, given the fact that the services are publicly funded and run. The local
authorities have a high degree of autonomy, the professionals are in many cases unwilling to
accept changes in their practices. The governmental policy is imprecise in itself, and the
strategies to implement the policy are weak in the sense of legislation and directives. Strategies
actually utilized during the last decades are the production of series of governmental
commissions& rsquo; reports, short-sighted funding for projects, and the production of “general
advice for good practice”. Conclusions: The federal steering mechanisms have to adapt to actual
conditions in the field of practice. This will mean that a multitude of strategies have to be used;
the pre graduate training, and the continued training of professionals has to be modernized. But,
of outmost importance is that the service providers are made to organize themselves in
accordance with evidence based practice.
2.
A typology of advance statements in mental health care
Claire Henderson,1 Jeffrey W. Swanson2, George Szmukler3, Graham Thornicroft3 and
Martin Zinkler4
1
VISN 3 MIRECC, James J. Peters VA Medical Center, New York2. Services Effectiveness
Research Program in the Department of Psychiatry & Behavioral Sciences, Duke University
Medical Center, Durham, NC3. Health Services and Population Research Department, Institute
of Psychiatry, King’s College London 4. East London and The City Mental Health NHS Trust
Objective: Advance statements documenting mental health service consumers’ preferences for
treatment during a future mental health crisis or period of incapacity have gained currency in
recent years. Several kinds have emerged—some as legal instruments, others as treatment
planning methods. Our objective was to make a formal comparison among them. Method: This
paper reviews the English and German literature to develop a comparative t ypology of advance
statements: joint crisis plans, crisis cards, treatment plans, wellness recovery action plans TM, and
psychiatric advance directives (with and without formal facilitation). Results: The features that
distinguish them are: the extent to which they are legally binding; whether health care providers
are involved in their production; and whether an independent facilitator helps with their
production. Conclusions: The differing nature of advance statements is related to the diverse
models of care upon which they are based and the legislative and service contexts in which they
have been developed. However, there is recent convergence between the UK and US with
respect to research interventions which facilitate the production of advance statements, as
evidence emerges for the effectiveness of facilitated psychiatric advance directives and joint
26
crisis plans. Different types of advance statements can coexist and complement each other.
However, the relationship of advance statements to involuntary treatment is problematic, as is
their effective implementation in many mental health service settings.
3.
The use of health services and supports for mental health problems in ireland: piecing
together the jigsaw
Donna T Doherty
DT Doherty & R Moran Mental Health Research Unit, Health Research Board, Dublin
Objective: There is little information available on mental health in the Irish population or on the
use of health services or supports for mental health problems. This survey sought to address this
gap. Methods: This was telephone survey of a nationally representative random sample of 2,711
adults aged 18 years and over and living in private households. Measures included the GHQ12,
self-reported mental health problems in the previous year and attendance at a range of health
services and professionals for mental health problems. Results: A total of 12% of respondents
reported significant psychological distress, while 14% reported mental health problems in the
previous year. One in ten respondents reported attending the GP while 6% reported attend ance
at mental health services. Few respondents had attended other health professionals or supports.
This data was combined with that from other sources detailing service use for mental health
problems. Conclusions: These findings have policy implications in a range of areas including
public health, health promotion and health services. There is a need for the recognition and
acknowledgment of the extent of psychological distress in Ireland at the individual and societal
level. Reluctance to do this leads to underdeveloped and underused informal and formal
supports. There is a need to develop services in primary care to ensure that GPs are sufficiently
trained and have access to a range of mental health professionals that are appropriately trained to
support people experiencing distress. Finally there is a need to develop and evaluate care
pathways and referral patterns between primary and secondary health services to ensure that the
needs of those with mental health problems are being met.
4.
Psychiatric Beds Utilization In Two Differently Organized Community Mental Health
Service Systems. Northern Norway. The Velo-Project.
Lars Henrik Myklebust1, Knut Sørgaard1,2,3, Svein Bjorbekkmo2, Asle Nymann2, Stian
Molvik2, Reidun Olstad1,3
1
Psychiatric Research Centre of Northern Norway, University Hospital of North Norway2 The
Nordland Hospital Trust, Bodø, Norway3 The University of Tromsø, Institute of Clinical
Medicine, Department of Clinical Psychiatry, Tromsø, Norway
Objective. The literature yields contradictory and inconclusive findings on the dynamics
between community- and hospital-services, calling for further investigations on the on the need
and organization of psychiatric beds in contemporary de-institutionalized service systems. The
Norwegian VELO-project provides an opportunity to explore a close to natural experiment, due
to striking dissimilarities in two neighbouring Community Mental Health Centres with otherwise
strong similarity in catchment-area characteristics. The first constitutes a “central-bed” service
system, while the other a “local-bed” service system. The different organisation was expected to
affect the systems overall utilization of beds, the diagnostic population of inpatients, and the
ratio of local psychiatric beds to sheltered homes in the municipalities. Methods. The specialistservices case-registries were used, in addition to questionnaires on the municipality-services.
Results. No differences in the number of inpatients, total number of inpatient 24-hour periods, or
me an length of stay were found. Inpatient population showed only significant differences for
substance abuse. The number of sheltered homes in the municipalities was positively correlated
27
with the provision of local psychiatric beds. Data also suggested a need for psychiatric beds at
approximately 1 per 1000 inhabitants. Conclusion. Local or central provision of psychiatric beds
may not influence utilization. An under-utilization of available bed-resources was found in both
systems. Ratio of psychiatric beds and other types of residential care do not equilibrate. The
results may have implications for central theories in the field by Roemer, Goldberg & Huxley,
and Thornicroft & Tansella.
5.
Toward Stepped Care For People With Depression: Action Research In Community
Mental Health Centers
Stefanie Everaert, Gert Scheerder, Iris De Coster & Chantal Van Audenhove LUCAS,
Interfaculty center: KU Leuven, Belgium Supported by the Flemish government
Objective It is the aim of this project to define the specific role of the Flemish community
mental health care services (CMHS) in a perspective on "balanced care" and stepped care for
people with depression. CMHS are services that provide multidisciplinary, ambulatory mental
health care in the community. Method The first research year concerns a SWOT – analysis of
the current care program for people with depression in the CMHS. The current procedures for
intake and therapy choice and the treatment modalities are analyzed in representative samples of
patients with depression using the help of CMHS in the province of West-Flanders. The current
approach is compared with guidelines and evidence based practice in the field of treatment of
people with depression. These results are presented and discussed on brainstorming sessions with
the CMHS, which resulted in specific spearheads to optimize their care program in the second
research year. Results The SWOT – analysis resulted in different points of discrepancy, this
regarding the detection, the diagnosis, the treatment choice and the treatment of depression.
Strengths are the reflective attitude of individual therapists and the approach of suicidality. But
the CMHS do not fulfil a key position in a stepped care approach of depression. Conclusions.
The future role of the CMHS in the care for people with depression and the necessity of
innovation processes are still under discussion.
6.
Community mental health services in sweden – organisational structure, inter organisational relations and service Provision
Urban Markström1, Rafael Lindqvist2
1
Dept of Social Work, Umeå University, Sweden, 2Dept of Social Work, Göteborg University,
Sweden
Objective: The Swedish mental health reform of 1995 signified an increased responsibility for
the municipalities to provide social support and rehabilitation to persons with psychiatric
disabilities. The aim of this study was to describe and analyse the organisational structure and
the types of services provided by local welfare agencies. How are services organised, delivered
and designed and what is the underlying rationale? Methods: Ten Swedish municipalities were
selected and studied. The data consists of official documents (policy programs, action plans etc)
as well as 100 semi-structured interviews with politicians, managers, case workers and
representatives of user organisations and the psychiatric care system Results: Work modes
differed significantly between the municipalities. Services seemed first and foremost to be
designed for a ”historic” target group consisting of older persons with schizophrenia. Group
residences, organised daily activities and sheltered work arrangements were key elements in the
service system. A participatory and rehabilitative perspective was often lacking. The needs and
expectations of young people, with for instance neuropsychiatric disabilities and/or drug abuse,
were rarely met. Services were not designed according to evidence-based practices. The
cooperation between CMH-units and the psychiatric care system was well established. The
28
study indicates however an underdeveloped cooperation with labour market authorities and
employers. Conclusions: The Swedish community mental health system is fragmentary and in
need of more evidence-based knowledge, standardised work modes and a clear-cut
organisational structure. A “caring philosophy” and generous support seem to be the underlying
rationale. National policy directives emphasising the needs of people with psychiatric disabilities
are needed for such new developments to occur.
VII. OUTCOMES AND NEW TREATMENT STRATEGIES
1.
Recovery and quality of life: relationship with symptomatic and functional remission in
first episode psychosis
Durk Wiersma, Lex Wunderink, Sjoerd Sytema, Fokko J. Nienhuis
Department of Psychiatry, University Medical Center Groningen, University of Groningen, The
Netherlands
Introduction: Generally agreed outcome criteria in psychosis are required to evaluate the
effectiveness of new treatment strategies and surmount therapeutic pessimism. The aim of this
study is to explore symptomatic and functional remission in first episode patients and to find
predictors of recovery, defined by having achieved both symptomatic and functional remission.
Method: In a sample of first episode patients (N = 125) symptomatic and functional remission
during the last nine months of a two years follow-up period were examined, as well as recovery
and its predictors. Results: Half the patients (52.0 %) showed symptomatic remission, a quarter
(26.4 %) showed functional remission, while one fifth (19.2 %) met both criteria-sets and might
be considered recovered. Recovery was significantly associated with short duration of untreated
psychosis, but not with subjective quality of life. Conclusion: Symptomatic remission is less
selectively associated with recovery than functional remission. Treatment delay is associated
with less chance of recovery.
2.
Long-term studies of early psychosocial intervention in schizophrenia. 20-year follow-up.
Andrzej Cechnicki
Community Psychiatry Unit, Chair of Psychiatry, Jagiellonian University, Cracovian
Schizophrenia Research Group
Background. The Cracow Study on the Course of Schizophrenia is a prospective study, “from
the first episode of the psychosis” through the years of living with the illness. The 1, 3, 7, 12 and
20 years follow-up was made. Aim: The aim of study was to assess the results in 20 years
follow-up in the individual (ITP) and the psychosocial (PTP) treatment programme. PTP in
contrast to the individual treatment programme included the treatment in day treatment centres,
psycho-education for families, community group programme. Subjects and Method: 66 DSM
III schizophrenia diagnosed patients (mean age 47) took part in a direct clinical follow-up
examination (i.e. 82% of the preliminary group n=80). Among others the Predictors Chart,
Follow-Up Chart, BPRS and Lehman’s Quality-of-life Questionnaire were used. Results: 1/ The
patients spent 92% - ITP vs. 93% PTP of the follow-up time in the community 2/ During of 20
years of follow-up three patients (4,5%) committed suicide; 3/. According to the GAS scale for
58% of the ITP vs. 48% in the PTP the result was positive (over 60 points in GAS, the difference
- 10 points); 4/ Relapses become more frequent in the subsequent years; 94% in ITP vs. 77% in
PTP after 20 years. (the difference - 17 points). 5/ The number of re-hospitalisation during 20
years was 80% in ITP vs. 60% PTP (the difference - 20 points); 6/ Throughout the 20 years, the
average period of inpatient treatment was 86 weeks in the ITP vs. 70 weeks in PTP (Mann29
Whitney test p=.03). 7/ At the 20th year follow–up the patients living with their procreative
family: ITP – 67% vs. CTP – 45%; generative and procreative family in shared housing: ITP –
3% vs. CTP – 3%; living with generative family: ITP – 24% vs. CTP –23%; independent but
living alone: ITP – 0% vs. CTP – 29%; living in Social Care Home: ITP - 6% vs. CTP – 0%. 8/
After 20 years 27% in ITP vs. 36% PTP of the patients remain active on the labour market (the
difference - 9 points). Conclusions: The three years psychosocial treatment programme after
first hospitalisation of patients suffering from schizophrenia is more favourable than the
individual treatment programme only in clinical level, and the continuous benefits last for 20
years of illness.
3.
Treatment Pathways For First-Episode Psychotic Patients Within Community BasedMental Health Services In The Veneto Region. Preliminary Findings From The Picos
Mirella Ruggeri, Bertani M., Lasalvia A., Bissoli S., Bonetto C., Cristofalo D., De Santi K.,
Lazzarotto L., Marrella G., Mazzoncini R., Pellegrini N., Tosato S., Tansella M. & Ruggeri
M. on behalf of the PICOS -Veneto Group
Department of Medicine and Public Health, Section of Psychiatry and Clinical Psychology,
University of Verona, Italy.
Objective: The most recent international guide-lines suggest the adoption of specific treatment
pathways for patients at their first psychotic episode. This study investigates the typology of
interventions provided to first-episode psychotic patients from “real world” community basedmental health services and to which degree guidelines recommendations are met in the clinical
practice.Methods: This study was conducted in the context of the Psychosis Incident Cohort
Outcome Study (PICOS), a large multisite research taking place in the Veneto Region (Italy),
aiming to characterise patients experiencing their first episode of psychosis and to develop a
comprehensive predictive model of outcome, by integrating clinical, social, genetic and MRI
data. Interventions provided to patients included in the study were retrospectively collected from
patient records at 1-year follow-up. An ad hoc schedule was used which collected detailed
information on both pharmacological and psycho-social treatments. Results: Data refer to a
preliminary sample of 75 patients. No participating site had ever developed any specific and
dedicated services for first-episode psychosis. Standard care in the participating sites generally
consisted of a regimen which combined outpatient psychopharmacological treatment with nonspecific supportive clinical management. Specifically, the great majority of patients (94%) had
been prescribed neuroleptic medications (the two most frequently used were olanzapine and
haloperidol, prescribed respectively to 45% and 44% of patients). Only one half of the sample
(48%) received some kind of psychosocial intervention, generally represented by unstructured
individual support therapy. Psychodynamic-oriented psychotherapy or other specific
psychotherapeutic interventions, such as CBT (strongly recommend in the recent treatment
guidelines) were seldom provided (less than 15%). Interventions for family members generally
consisted of non-specific informal supportive/ educative sessions; specific family psychoeducation (strongly recommended in the recent treatment guidelines) was provided to less than
8% of caregivers. At one-year follow up, 89% of patients were still contact with treating mental
health services and 66% were still receiving specialised intervention. Conclusions: Our
preliminary findings highlighted some discrepancies between interventions generally provided
within “real world” mental health services and the best treatment options recommended by the
most recent guidelines. This suggests the need to implement specific and large scale initiatives
aiming to close the gap between research and clinical practice.
30
4.
Effectiveness of the Psychiatric Rehabilitation approach in the Netherlands, two year
follow-up
Harry Michon1 (presenter), Wilma Swildens2, Jooske van Busschbach3
Altrecht mental health care2, University of Groningen Department of Psychiatry3, Trimbos
Institute1
This presentation highlights the results of a multi-site Randomised Clinical Trial on the
effectiveness of the Psychiatric Rehabilitation approach (PR; Anthony et al 2002). Although PR
is widely applied in the Netherlands, no controlled effectiveness studies were available. Study
questions (in this particular presentation). 1. is PR more effective than rehabilitation as usual
regarding goal attainment in mental health clients with severe mental illnesses, one and two
years after starting the intervention. 2. Is PR more effective than rehabilitation as usual regarding
goal attainment in the sub-sample of clients with vocational goals. Methods. The stud y is
designed as a Multisite Randomised Clinical Trial (RCT), comparing:- Psychiatric rehabilitation
(PR) by fully trained rehabilitation workers (EXP) and-‘rehabilitation as usual’ by case
managers/ psychiatric –MHC nurses with no PR training (CC). A total of 157 patients were
included in the RCT: 81 EXP and 76 CC. The sub-sample of clients with vocational goals (paid
work or other daily activities) consists of 69 clients. The study only included clients who at the
start expressed specific wishes for change in the rehabilitation outcome domains: living, work,
learning, daily activities and social contacts. The primary outcome criterion is goal attainment as
judged by clients themselves. Secondary outcome criteria are (changes in) functioning,
empowerment, quality of life and (met and unmet) needs for care. Fidelity criteria for the
performance of PR in the experimental condition were developed at the start of the study. The
first part of the study, focussing on measuring the short term effectiveness of PR (after one year)
was presented at the Enmesh 2006 conference. This presentation is concerned with the second
part of the study, which was directed at the longer term effectiveness (outcomes after two years).
We will focus on the results after two years and possible similarities and differences between one
year, and two year findings.
5.
Maintenance Antipsychotic Medication: How Much Do Patients And Staff Agree?
Helen Nightingale, Kathryn Davies and Tom Burns
Department of Psychiatry, University of Oxford, UK
Objectives: Relapse prevention or minimization is a critical step in stabilizing patients’ social
functioning to permit effective rehabilitation. The evidence that maintenance medication reduces
relapses in schizophrenia is overwhelming. There are international guidelines on the duration of
maintenance but practice varies internationally. It is also unclear how much both clinicians and
patients are aware of these guidelines, or how much clinicians follow them. This UK arm of a
European study aims to identify practice and knowledge. Methods: Questionnaires were
distributed to clinical teams managing patients with schizophrenia to collect data on their
knowledge and use of guidelines. These were analyzed for psychiatrists / nurses /others. Patients
with sc hizophrenia were asked the same questions as part of a longer interview. Results:
Doctors were marginally better informed than nurses and significantly more so than other team
members. They were also much more likely to follow or exceed the guidelines. Knowledge of
the guidelines for maintenance after a first episode was much less widespread and less associated
with practice. Conclusions: There is a range of knowledge and practice within the
multidisciplinary team and between clinicians and patients on this very fundamental component
of treatment. The reasons for this are potentially complex and deserve exploration.
31
VIII. COERCIVE TREATMENT IN PSYCHIATRY: A EUROPEAN RESEARCH
UPDATE
1.
Predictors Of Involuntary Hospital Admission Across The Eunomia Study Sites
Thomas Kallert
1
Department of Psychiatry and Psychotherapy, University Hospital Dresden, Germany
2
Parkkrankenhaus Leipzig-Südost, Klinik für Psychiatrie, Leipzig, Germany
Objective: Previous research has shown a specic prole of risk factors characterizing patients
who are legally involuntarily admitted to psychiatric hospitals: younger age, diagnosis of
psychotic disorder and/or mental retardation, manic symptoms, and male gender and/or nonCaucasian ethnicity. Methods: The naturalistic and epidemiologically oriented EUNOMIAstudy design in 13 sites in 12 European countries used a standardized battery of instruments (e.g.
psychopathology, legal status, perceived coercion, satisfaction with treatment) to assess two
groups of patients: legally involuntarily admitted patients and legally voluntarily admitted
patients who feel coerced to admission. Uni- and multivariate analyses on the data are
performed, and a logit-model for predicting involuntary hospital admission was developed.
Results: This presentation is based on 2,586 legally involuntary and 830 legally voluntary
patients included in the study. General and site-specic dierences between the two subgroups of
patients focusing on the initial assessment within the rst week after hospital admission covering
their socio-demographic and clinical characteristics, legal status, perceived coercion and
satisfaction with treatment will be highlighted. Further, details of the statistical model predicting
involuntary adm ission will be demonstrated. Conclusions: Consequences for clinical practice of
involuntary hospital admissions across Europe will be demonstrated.
2.
Clinical and social outcomes of a) legally involuntarily admitted patients and b) legally
voluntarily admitted patients who felt coerced at admission. A comparison across the
EUNOMIA study sites.
Matthias Schützwohl, Thomas W. Kallert, and the EUNOMIA-study group
Germany
This is an oral presentation within the following symposium: Coercive treatment in psychiatry: A
European research update. Aims. To compare the clinical and social outcomes between legally
involuntarily admitted patients and legally voluntarily admitted patients who felt coerced at
admission. Methods. Within the EUNOMIA-study, N = 2,586 involuntarily admitted patients
and N = 830 voluntarily admitted patients who felt coerced at admission were recruited across 13
sites in 12 European countries. Within the first ten days, 4 weeks, and 3 months after admission,
patients were assessed on several variables including psychopathology (BPRS), level of
functioning (GAF), QoL (MANS A), and satisfaction with treatment (CAT). The follow-up
ratings of the two groups of patients will be presented and compared by means of multivariate
analyses. Results: First analyses revealed that involuntarily admitted patients and voluntarily
admitted patients who felt coerced at admission both showed significant clinical improvement in
terms of observer-rated psychopathology and social functioning four weeks after admission.
However, about 20-30% of involuntarily admitted patients and about 10-20% of voluntarily
admitted patients who felt coerced at admission looked negatively upon their treatment and
stayed dissatisfied later on. Conclusions: It appears important to learn more about those patients
who were dissatisfied with treatment, especially in terms of the medium-term and long-term
outcome of treatment.
32
3.
Quality of life and social functioning of involuntarily admitted patients - the EUNOMIA
study.
Rymaszewska Joanna, Andrzej Kiejna
Wrocław Medical University, Poland
Objective: to evaluate quality of life and social functioning of psychiatric patients admitted
legally involuntarily and legally voluntarily but feel coerced. Method: Involuntarily admitted
patients (n=823) and voluntarily who felt coerced based on MacArthur Admission Experience
Survey (n=286) from 8 European centers were assessed at 3 time-points: at admission, 4 and 12
weeks after admission. The Short Assessment of Quality of Life (MANSA) and Global Social
Functioning (GAF) were used. Several further factors were analysed by regression models:
psychopathology (Brief Psychiatric Rating Scale), Cantril Ladder of Perceived Coercion,
Modified Overt Aggression Scale (MOAS) and Client’s Assessment of Treatment (CAT).
Results: 28% involuntarily patients were employed, 32% pensioned (28%, 41% respectively in
voluntary group). There were no differences in sex, age, education or duration of disorder in both
groups. Higher QoL was associated with better social functioning, being employed, married,
having manic/excitement symptoms and also with involuntarily admission and higher verbal and
physical aggression. Overall psychopathology, autoagression as well as diagnosis of depression
and personality disorders were negatively correlated with QoL. In forward-backward stepwise
selection model depressive symptoms, being unemployed or pensioned, living in Prague or
Wroclaw and feeling coerced during voluntary admission predicted lower QoL in each measure
point, whereas social functioning and satisfaction of treatment, manic symptoms, living in
Vilnus, Orebro or London predict higher QoL. Conclusions: Subjective feeling of being coerced
during psychiatric admission predict lower quality of life even after 3 months of treatment.
References: Kallert T. et al. The EUNOMIA project on coercion in psychiatry: study design and
preliminary data. World Psychiatry 2005;4(3):168–172.
4.
One year outcomes of involuntary hospital admissions in England
Stefan Priebe and the Involve study group
Barts and the London School of Medicine, Quenn Mary, University of London
Objectives: To assess one year outcomes of involuntary hospital admissions in England.
Methods: Data of 1570 consecutive patients who were involuntarily admitted to psychiatric inpatient care in England were obtained. Ca. 50% were interviewed within the first week after
admission, and 378 were re-interviewed at one year. Outcome criteria were involuntary readmissions within one year following admission and patients’ views at one year as to whether
the index admission was justified. Results: Within the one year period 15% of patients were
involuntarily readmitted, and 40% felt at the one year follow up that the index admission was
justified. Patients’ initial views of in-patient treatment were the best predictor of both
readmissions and retrospective justification of the index admission. Patients who expressed a
higher satisfaction with treatment within the first week of involuntary in-patient care had lower
readmission rates and felt more often that the index admission was justified. Conclusions:
Patients’ views of involuntary treatment are an important prognostic indicator and should be
elicited even at an early stage when symptom levels can still be high.
33
5.
Adverse events in psychiatry identified by a no-fault patient-insurance an example of
qualitative mental health services researchjerker Hanson
Jerker Hanson
MD, Phd D, associate professor, Karolinska institute, Stockholm.Claes-Göran Westrin, professor
emeritus, Department of Public Health and Care Research, University of Uppsala.
Background: Health services research is a smorgasbord of questions, whose handling implies
different designs, materials and methods and interaction between research and clinical practice.
Systematic registration of reasonably clear-cut ’adverse events’ such as cases of orthopaedic
malpractice were shown to be useful. Routine reporting of more complex events in psychiatry
has been less successful. In this context studies of claims to an obligatory no-fault patient
insurance may offer some particular opportunities. The prospects of economic compensation as
well as psychological rehabilitation ma y increase the patient’s motivation to report harmful
incidents. The no-fault rules may even motivate doctors and other health care personnel to
indemnify the patient for the inflicted harm. Objective: To report the use of claims to the
Swedish no-fault insurance in quality development and qualitative mental health services
research. Methods: 1210 claims to the no-fault insurance covering almost all health care in
Sweden concerning psychiatric care were analyzed regarding compensability and importance for
quality development in psychiatric care. Results: 245 claims were considered to justify
compensation. Especially suicide in hospital, and medically demonstrable harm caused by
medication and ECT could be referred to specific shortcomings in the process of care. Harm
caused by missed diagnoses of depression, ADHD and As perger´s syndrom were less frequent
than expected. Many complaints concerned relations to staff, especially psychiatrists and their
behaviour. (Further examples will be presented). Conclusions: Claims to a no-fault patient
insurance may indicate important shortcomings in the process of mental health care and provide
material for quality development and qualitative mental health research.
IX. ASSESSMENT IN MENTAL HEALTH SERVICE
1.
A national investigation of mental health inpatient staff morale in England.
Fiona Nolan, Sonia Johnson
University College London
Objectives: Little is known about levels of morale on UK psychiatric inpatient wards and the
factors influencing it. Improving the quality of care on psychiatric inpatient wards has been a
major focus in recent mental health policy, a recurrent criticism being that contact between staff
and patients is limited in time and therapeutic value. Change is unlikely to be achieved without
recruitment and retention of a high quality and well-motivated work force.
This study is intended to inform service planning and policy by delivering evidence on the
morale of the inpatient mental health workforce and the clinical organisational, architectural and
human resource factors that determine it. Methods: The study has six components: a
quantitative questionnaire for approximately 2000 staff on inpatient wards, a comparison group
of 600 community staff, qualitative investigations of 10 case study wards, a follow up
quantitative component of 20 wards, an investigation o f staff reasons for leaving, and an
architectural evaluation of each site. Results: A hundred wards in nineteen mental health trusts
have been recruited to the study. All clinical staff on these wards are being surveyed, and data
34
also collected on organisational and architectural characteristics. Then study methods and
settings will be outlined. Data collection will be completed in early 2008, and in this presentation
we will describe levels of morale, satisfaction and well-being at work and their variations across
settings. Conculsions: The implications of our findings for local service planning and national
policy, as well as for further research in this area, will be described.
2.
Measuring mental health services’ responsiveness to service users expectations
Anke Bramesfeld
Germany
Background and Objectives. Health systems increasingly try to make their services more
responsive to users’ expectations. We used the responsiveness concept developed by WHO to
evaluate the performance of mental health care in a catchment area in Germany. Method
Responsiveness for inpatient, outpatient mental health care and housing was evaluated by a
standardised questionnaire. Responsiveness was assessed in the following domains: attention,
dignity, clear communication, autonomy, confidentiality, basic amenities, choice of health care
provider, continuity, and access to social support. Users with complex mental health care needs
were recruited consecutively within the mental health services provided in the catchment area of
the Hanover Medical School. Results 227 persons were recruited in outpatient care and 91 in
inpatient care. 56 persons, recruited in outpatient care lived in hostels and were also interviewed
on hostel responsiveness. Service users reported in general more often poor responsiveness on
inpatient care (26 %) than in hostel care (21 %) or outpatient care (15 %). The best performing
domain in all care forms was confidentiality; the worst performing was choice, closely followed
by participation. Participation was rated second most often by service users in in- and outpatient
care as the most important domain. In hostel care attention and respect were rated as most
important domains. Discussion and conclusions. The results are similar to prior responsiveness
surveys with regard to the overall better performance of outpatient care. The more choice
patients have not to use a service, the more those service users remaining in a service will report
that their expectations are met. Patient priorities differ in respect to service user groups. The
various services have different abilities to meet patients expectations in the domains that they
prioritise.
3.
What Do They Really Do In A Psychiatric Outpatient Department?
Leif Wahlqvist
Leif Wahlqvist, North Eastern Department of Psychiatry, Stockholm County Council, Sweden,
Danderyd Hospital, Danderyd, Sweden
Objective: 85-90% of the psychiatric patients in Sweden are treated exclusively in outpatient
care. The outpatient team is composed of psychiatrists, psychologists, social workers and
psychiatric nurses. An irritating fact is that in average only two patients are seen per day by one
person in the staff.. Therefore, politicians stipulated 2007 that every staff member should have at
least 800 visits/year. Othervise the budget should be reduced next year. Few members of the
staff reached the goal. Methods: For this reason, six outpatient psychiatric departments in
Stockholm was studied. The aim was to measure the time used for different activities and
investigate how the work could be performed more effectively. During two weeks 164 staff
members reported each day how much time had been spent in eight categories: direct work face
to face with individual patients, indirect administrative work for individual patients ( keeping
records, issue certificates etc), planning conferences concerning several patients, education of
staff, administration, transportation, vacation, abscence due to illness. Results: 32% of the
working time was utilized for direct work with patients and 34% was used to indirect
35
administrative work. Absence from work due to education was 10%, and remaining categories
24% of the time available. Nurses utilized considerably less time to indirect work compared to
psychologists and doctors. 49% of the indirect administrative work was spent on keeping
records. Conclusions: Indirect adminstrative work, especially documentation, takes a
considerable part of the time available for work with patients. Better systems for documentation
and education of staff in documentation should probably increase time available for direct work
with patients and make it possible to achieve the goal.
4.
National Survey Of In- And Outpatients And Their Relatives In Danish Psychiatry
Torsten Munch-Hansen
Center for Kvalitetsudvikling, Denmark
Objective. To gain detailed nationwide information about how treatment quality and contacts
between relatives and psychiatric staff is perceived by patients and their relatives. Methods. In
spring 2005 the staff in all wards handed over questionnaires to patients when having a face to
face contact, and at the same time asked for permission to send a questionnaire by post to one
relative. Different questionnaires were applied for inpatients, outpatients and relatives. The
questionnaires contained 20–25 attitudinal items, a few questions about socio-demographic
characteristics, a question about the patients’ diagnoses and 3 open ended questions. 20.712
patients and relatives answered a questionnaire. Response rates vary from 48 (relatives to
hospitalized patients) to 67 (outpatients). Results. It appears that patients assess their treatment
more positively than relatives assess their contact with staff. Furthermore, levels of satisfaction
vary a lot from ward to ward. This variation is not only due to variations in respondents’ sociodemographic characteristics and the patients’ specific diseases, but is also explained by factors
such as work practices genuine to each ward. Patients perceive the information they receive
about their disease and treatment as insufficient. Likewise patients evaluate their own
involvement in treatment and care less positively. The relatives are most positive regarding the
clinical staff’s treatment of the patients, and least positive regarding their own involvement in the
treatment. Conclusions. The results are published in ways that allow wards to compare their
results with results of compatible wards. Thus, each ward can identify areas where treatment and
information practices can be improved. Because the data collection process was successful and
response rates higher than expected it has been decided to repeat the data collection every third
year.
5.
Relatives More Critical Than Patients To Services
Torleif Ruud1, Rolf W Gråwe2
1
Akershus University Hospital, Oslo, Norway
2
Senior Researcher, SINTEF Health Research, Norway
Objective: Compare how patients and their closest family members assess the services given by
community mental health centres (CMHCs). The study is a part of an evaluation of eight
CMHCs in Norway. Methods: Questionnaires with partly similar questions on the community
mental health services were distributed to patients, and to the person they define as their closest
family member for the patients who gave written consent to this. The data were linked to
registrations and assessments made by the clinicians for patients who had given written consent
to such linkage. Data could be linked from all three sources for 382 patients. Results: 64% of
the relatives lived together with the patient and most of the rest saw the patient once a week or
more. 57% were spouses/partners, 28% parents, 5% children and 4% siblings of the patient. The
views of the degree of improvement in symptoms, functioning, relationships and other areas
were rated fairly similar by patients and relatives. The ratings of the services given were in
36
general less positive by the relatives compare d to the patients, both regarding waiting time,
treatments given, attitudes of the staff and other aspects. The relatives wanted to be more
involved in the treatment than they felt that the patient and the clinicians wanted them to be. The
results are discussion in relation to patient characteristics and the relation between the patient
and the family member. Conclusions: The more negative experiences by the patients’ closest
family members may indicate that clinicians are too restrictive and not supportive enough in
their contact with relatives of the patients, also limiting how these may contribute in the
treatment.
6.
Associations Between Medication Non-Adherence And Resource Use And Costs For People
Taking Medication For Depression
Derek King1, Martin Knapp 1,2
1
PSSRU, LSE Health and Social Care, London School of Economics; 2Centre for the Economics
of Mental Health, King’s College London
Objectives: To assess the relative impact of non-adherence and other factors associated with
resource use and costs by people with depression. Methods Secondary analyses of data from
the 2000 UK Psychiatric Morbidity Survey (PMS). Patients who reported taking antidepressants
at the time of the survey were included in the study. Responses to the CIS-R and an algorithm
based on the ICD-10 diagno stic criteria were used to assess the severity of depression. Selfreported data were used to assess non-adherence to medication. With respect to use of services,
data on the use of inpatient care, outpatient care, day activity centres, community care and GP
services are included. The unit costs applied to service use were taken from the Personal Social
Service Research Unit compendium of estimates of long-run marginal opportunity costs in the
UK. Costs associated with time off employment attributable to mental illness were also
included. The association of non-adherence on resource use and costs was examined using twopart models which included relevant covariates. Results Within the PMS, 461 people were
taking antidepressants. After accounting for co-variates such as age, sex, ethnicity and education
level, non-adherence was associated with higher service use and costs in the sample of people
taking medication for depression. Prior analysis of similar data determined that in people taking
antipsychotic medication, this association was also present. Conclusions Resource use and
costs are influenced by various factors. Medication non-adherence consistently exhibits an
association with higher costs in patients suffering from depression.
X. FAMILLY CONTEXT IN RESEARCH AND THERAPY
1.
Family Burden Of Patients With Affective Disorders
Joanna Borowiecka-Kluza, Dominika Dudek
Department of Psychiatry University Hospital, Krakow
Background: Family burden has been defined as "an effect of a psychiatric disorder on people
living with a patient", or a "problem caused by a patient". Further attention was paid to burden
management, the relation of the burden to different aspects of family functioning, and possible
positive impact of the burden on the family life. Objective: Our research was focused on the
burden of spouses of patients with affective disorders on style of stress management, and
marriage functioning. Methods: Patients fulfilling ICD 10 criteria of recurrent depressive
disorder (F33) or bipolar affective disorder (F31) were invol ved in the study. The inclusion
criteria were: 18-65 years of age, remission phase of the disorder, no psychiatric history in
spouses. Both patients and their spouses were interviewed to get the sociodemographic data and
37
medical history. The stress management style and marriage satisfaction, as well as spouses’
burden level and current medical condition were assessed. Results: There exists a connection
between the burden of spouses of patients with unipolar and bipolar affective disorders and: 1)
the style of stress management, 2) the style of family functioning and level of marriage
satisfaction, 3) current condition of the spouses’ mental health , 4) chosen aspects of the course
of illness of the patient. Conclusions: The results of the study are implying the need of the
therapeutic offer directed not only to patients with affective disorders but also to their spouses.
2.
E-Health, Depression And Family Support
Sigrid Stjernswärd, Margareta Östman
Health and Society, Malmö University
Objective: Depression affects the depressed person and his/her closest network. The aim of this
project is to explore a way to support the relatives of persons with depression via a tool based on
digital technology. The expanding use of Internet technology worldwide makes it an interesting
tool for the spreading of health related information and communication online.Methods:
Eighteen relatives were interviewed individually or in focus groups to explore their experiences
of living close to a person with depression. Nurses specializing in psychiatric care were
interviewed to explore their thoughts about and experiences of meeting relatives within
psychiatric care. A digitally based tool will be developed through an iterative process with the
aim of alleviating the relatives’ situation. Eventually, it will be evaluated in cooperation with the
concerned parties. Results: Most relatives were affected by the depression and experienced a
feeling of not living their own life, struggling to balance relationships, re-evaluating and
adapting to the circumstances and trying to make their voice heard within the health care system.
The interv iews with the nurses are to be analyzed.Conclusions: Depression affects family
members, clearly giving rise to needs of information and support. Potential uses of the Internet
for health related matters need to be further explored in search for constructive and creative
solutions to address the needs of potential risk groups.
3.
Perception Of Family Relationships In Eating Disorders And Depression – Implication For
Psychotherapy
Barbara Józefik Ph.D., Maciej Pilecki Ph.D.,Dorota Okular M.A., Dominika Pindus M. A.
Department of Child and Adolescent Psychiatry of the Jagiellonian University Collegium
Medicum, Krakow, Poland
The aim of the study;
The aim of the research was to study, in the Polish cultural context, perception of family
patterns, in terms of autonomy and closeness, in the group of patients suffering from eating
disorders and depression and their parents. The presentation shows the results of the research
concerning the perception of familial relationships between patient and their parents and also
between patients’ parents and their parents.The method:
 Family of Origin Scale (Hovestadt et al.,1985)
 The Eating Disorder Inventory (Garner et al., 1993)All polls were standardised on a Polish
sample.
The subjects:
3 groups of eating disordered patients:
 Anorexia nervosa patients restricted type (n=54) and their parents (M n=53, F n=49)
 Anorexia nervosa bulimic type (n=22) and their parents (M n=21, F n=19)
 Bulimia (n=36) and their parents (M n=34, F n=31)
2 control groups:
38


Depressive patients and their parents (M n=37, F n=37)
Healthy girls and their parents (M n=85, F n=81)
Age of the girls 13 to 21.
Results





Autonomy disorders in the mothers’ families of origin have proven to be characteristic of
the whole group of eating disorders contrary to control groups. Eating disorders are
connected with patients’ mothers’ difficulties with attaining autonomy in their families
of origin.
Fathers difficulties in their families of origin concerned autonomy and closeness were
specific in anorexia restrictive type and bulimia.
Transgenerational pattern of relationships as meaningful factor for susceptibility to
cultural patterns.
Great diversity of family relations’ perception (“maps”) in the subtype of eating
disorders.
Therapeutic implications of findings will be discussed.
4.
From family intervention to collaboration with family
Józef Bogacz, Maria Wojnar, Cechnicki Andrzej
Community Psychiatry Unit, Chair of Psychiatry, Jagiellonia University, Schizophrenia
Research Group, Krakow
Objective: There will be presented different forms of collaboration with families of individuals
suffering psychotic symptoms. Methods: Narrative analysis of relatives participating in different
kinds of therapeutic groups as well as self-supporting groups and family associations. Results:
The first and still-existing idea was to enhance the therapy of an individual by helping his family
to change. The change could relate to different aspects of family functioning such as:
communication, rules making a family cohesive, a system of family meaning or family
narratives. The therapeutic aim was also to empower families to deal with problems connected
with experiencing psychosis by one of their member. As a result of empowerment the families
organize their association to create and influence actively different forms of rehabilitation and
professional engagement of their members suffering from psychosis. Conclusions: A change in
thinking about the way of work with families of an individual treated for psychosis can be
observed. In the beginning a family was mainly the object of influencing. The therapists knew
how the correct family should look like. Now we treat family as a partner who we meet in
therapy as well as in other projects like social firms, for example „U Pana Cogito”hotel. The
presentation ends up with 8min film made by Polish television, were the meaning of the family
in Polish context (40 – 50% patients are married) is presented.
5.
Normality Restoring In The Family
Wojciech Kordas, Marta Janiszewska, Katarzyna Warchoł, Krzysztof Walczewski
Specialist Hospital im. J. Babińkiego, Kraków
Background: Treatment and rehabilitation of psychotic patients from a perspective of
psychiatric inpatients ward, regarding family context is a complex issue. Nowadays work with
family, although widely practiced in environmental psychiatric care, is not yet a practically
accomplished standard in inpatients care. That is why we would like to share our experiences in
this matte r, that show how important, useful and effective this kind of work is. System of
treatment where individual therapy with patient, consultations with family, and encounter group
39
for families are carried parallely is a focus of our presentation. To illustrate it we would like to
present a history of one family we took care of in our ward and their struggling with illness.
Case: Young man (26) has been hospitalized many times. His remissions, except for the actual
one, were never longer than 3 months, the course of illness was acute, with a lot of aggressive
behaviors. Parallely with patient’s treatment, his mother has joined encounter group for families,
that was focused on the process that can be described as “normality restoring in family”.
Patient’s development and insight gaining were strongly connected with analogical processes in
his mother. Since then they both can live their lives freely and undertake new social roles, they
don't have to be "patient' and "caregiver", and they haven't been bothered by acute exacerbations
of psychosis. Conclusions: Families involved into treatment usually take much responsibility for
it on themselves, they become co-therapists so the border between repressive-caring- system of
psychiatric care and family diminishes. As a “normality restoring in family” we regard restoring
the proper, own order in family system. The relationship: therapeutic team – caregiver – patient
is transformed into relationship: therapeutic team – mother – son. From this perspective it is
easier to build relationships within the family regarding healthy resources of patient, which gives
space for further development.
XI. VOCATIONAL REHABILITATION
1.
Developing Evidence-Based Employment Rehabilitation Services
Goeff Shepherd1, Helen Lockett1, Miles Rinaldi2
1
Sainsbury Centre for Mental Health, 2Recovery & Social Inclusion, South West London & St.
George’s Mental Health NHS Trust
Objective: With the advent of ‘Individual Placement and Support’ (IPS) models, employment
rehabilitation for people with severe and enduring mental health problems is now founded on a
much more secure evidence base. There is a well established ‘fidelity scale’ which prescribes
the components of effective service delivery. However, this does not provide guidance with
regard to other features necessary for the development - and subsequent performance monitoring
- of evidence-based services. It is the objective of this paper to describe a project aimed at
producing a conceptual framework and indicator set which would cover this broader remit.
Methods: A multi-agency group was convened consisting of service providers (statutory and
independent sect or), commissioners, policy makers and national regulators. Using the available
evidence and knowledge of good practice, they developed a conceptual framework for the
indicator set which was then populated through a series of iterative discussions. The provenance
of each indicator was supported by either research evidence and/or current UK policy
considerations. A number of other criteria associated with reliability, face validity and ease of
collection were also applied. Results: The final framework consisted of 35 items, grouped under
4 headings: ‘contextual information’ (local employment rates, existing performance of local
services, etc.); ‘intake descriptors’ (the characteristics people receiving the services); ‘process
indicators’ (as assessed against current research evidence); and ‘outcomes’ (individual level
outcome data). Conclusions: This paper will present the framework, together with the results
from a feasibility study to check its practical utility. It will be concluded that it provides a
potentially useful tool for providers to evaluate the quality and effectiveness of their services and
for commissioners to improve local service specifications. It may also be of interest to regional
and government agencies who wish to aggregate the data ove r larger population areas.
2.
Social Inclusion at Work (revised version)
Justine Schneider
40
University of Nottingham and Nottinghamshire Healthcare Trust
Objective: To investigate social inclusion, or integration, in the workplace for people with
mental health problems, in the context of its theoretical and policy background. Methods: A
review of previous research on inclusion at work for disabled people identified indicators which
were brought together into a ‘social inclusion at work’ scale, which was applied in the
‘SESAMI’ study of 79 individuals with mental health problems in paid employment. The
Minnesota Satisfaction Questionnaire was also used, together with Rosenberg’s self-esteem
scale, the Herth hope scale and the Carers' and Users' Expectations of Services scale (CUES).
Results: The new scale covers different domains from the MSQ. Most people felt valued (75%),
were treated the same as other workers (74%) and were satisfied with the status of the job (73%).
O nly a minority (42%) thought that the job met their ambitions and even fewer (37%) socialised
with colleagues. Younger people had higher scores and social inclusion scores correlated with
self esteem, hope and aspects of the CUES. Conclusion: The quality of implementation of
supported employment is an issue for funders and providers but most research on this aspect has
been conducted at an organisational level, measuring objective outcomes like job placement and
tenure. In addition to these criteria of success, systematic measurement of social inclusion from
service users’ perspectives is both possible and desirable, as evidenced by the findings of this
exploratory analysis. Acknowledgement: The study on which this paper is based was financed
by the European Social Fund (http:www.sesami.org.uk) and six supported employment agency
partners made contributions in kind. The research team included Jan Slade, Melanie Boyce,
Robin Johnson, Jennifer Secker, Mike Floyd and Bob Grove.
3.
Barriers to work and employment of persons suffering from mental illness as viewed by
employers
Hubert Kaszyński, Andrzej Cechnicki, Igor Hanuszkiewicz
Community Psychiatry Unit, Chair of Psychiatry, Jagiellonian University, Schizophrenia
Research Group
Community attitudes toward persons suffering from mental illness are characterized by
stereotypical and false conceptions of mental illness, emotions based on fear and constant
readiness to avoid any kind of joint activity. They constitute one of the primary factors impeding
participation of people suffering from mental illness in community life, including work. The
study titled “Employers’ views on employing persons suffering from mental illness” was
designed by members of the Polish Psychiatric Association – the Małopolska Branch of the
Section of Community Psychiatry and Rehabilitation within the scope of the Partnership for
Development – the Cracow Initiative for Social Economy – COGITO. Its goal was to identify
barriers that hamper professional activity of persons suffering from mental illness. The study was
conducted by the Public Opinion Research Center (CBOS) in 2007, included 503 employers
from small and medium enterprises; an original interview questionnaire titled “Employers’ views
on employing persons suffering from mental illness” was used. The results indicate the existence
of an enormous problem of fixed stereotypes among employers concerning persons suffering
from mental illness. This kind of attitude is one of the fundamental barriers to work and
employment of persons who are socially vulnerable. Moreover, we emphasize the ignorance of
the principles of obtaining reimbursement for the work costs pertaining to the employment of the
disabled, the very instrument of the labor market policy intended to increase work accessibility
for the disabled. 77,7% of the interviewed employers stated that they would need assistance in
employing a person who had suffered from mental illness. The majority of the subjects (67%)
expect to be provided with information about the illness. At the same time, an equally important
expectation of the employers is to get assistance in obtaining reimbursement for the work costs
of employing a disabled person (60,4%) and support in obtaining funding from the European
Social Fund (60.2%). It should be noted, that the interviewees showed willingness to cooperate
41
with the psychiatric care system (56,3%), as well as openness to cooperation with job trainers
within the so called supported employment model (44,1%). Unquestionably, meeting these
expectations is of essential importance for any actions aimed at employing persons suffering
from mental illness. The key task in the area of broadly understood intermediate professional
rehabilitation is to plan effective educational activities which should include persons suffering
from mental illness.
4.
The Individual Placement and Support apporach to vocational rehabilitation for young
people with a first episode of a psychosis
Miles Rinaldi1, Rachel Perkins2
1
Head of Recovery & Social Inclusion
2
Director of Quality Assurance and User and Carer Experience South West London & St
George's Mental Health NHS Trust. UK.
Objective: The aim of this study was to evaluate the impact of implementing the Individual
Placement and Support approach (supported employment) with supported education within an
Early Intervention Team for young people with a first episode of psychosis in the UK. Methods:
Demographic, clinical and vocational data were collected between November 2001 and July
2006 to evaluate the impact on client vocational outcomes at 6, 12, 18 and 24 months.;
Individual vocational pathways are reported for the follow up periods along with social recovery,
in terms of vocation, and fidelity to the implementation of the IPS approach. Results: A total of
166 people were received a vocational intervention for at least 6-months. 12-month follow-up
data were available for 142 people, 18-month data for 106 people and 24-month for 67 people.
At baseline a total of 38% of people were in open employment (13%) and mainstream education
/training (25%). By 6-months, 69% of people were supported in open employment and
mainstream education / training and this rose to 81% at 18-months. The open employment rate
increased significantly from 13% at baseline to 48% at 18-months and this was maintained
through to 24-months. Conclusion: This study suggests that the Individual Placement and
Support approach combined with supported education appears to have been effective in enabling
people with a first episode of psychosis to gain and retain open employment an d mainstream
education leading to a full vocational recovery. In addition, this is the only study we are aware
of where previous employment does not predict future employment.
5.
Vocational Rehabilitation In Psychosis: The Eqolise Trial
Tom Burns1 and Jos Catty2 on behalf of the EQOLISE Group3 Thomas Becker (Ulm),
Durk Wiersma (Groningen), Toma Tomov (Sofia), Angelo Fioritti (Rimini), Wulf Rössler
(Zurich)
Department of Psychiatry1,
University of Oxford, UK, 2
St Georges, University of London, UK3
Objective: The last 20 years has experienced a significant shift in vocational rehabilitation in
mental health, away from traditional train-and-place to ‘place-and-train’ approaches. The most
widely researched of these place-and-train approaches is Independent Placement and Support
(IPS) and several US RCTs have demonstrated very significant advantages over high-quality
traditional rehabilitation measured as obtaining open-employ ment,. We tested whether IPS
demonstrated the same advantages in a European context (with substantially differing
unemployment rates, welfare provision and employment legislation to the US) and to test
whether differences in these contextual factors affected the impact of IPS within
Europe. Methods: Random allocation of 50 psychotic subjects within each of six European
countries to either IPS or local standard vocational rehabilitation. Subjects were followed up for
42
18 months by independent researchers. Primary outcome was obtaining open employment and a
series of secondary measures including duration of employment and social and clinical
outcomes. Results: IPS was significantly more successful in obtaining employment (54% versus
27%. P<0.001). IPS achieved more employment in all sites but this advantage was only
significant in four. The distribution of local effects reflected differences in welfare systems.
There was no evidence of clinical deterioration in those returning to work. Conclusions: IPS
appears to t ranslate successfully to Europe. However it does demonstrate sensitivity to welfare
and employment legislation and this multi-site trial provides important insights into its
adaptation.
XII. MEASURE OF GOOD PRACTICE
1.
Mental Health Policy as Process in a Global Context: Evidence-based Research in
Participatory Development
Robert Hayword
London
Objective: The future of mental health systems and services relies on the ability of all
stakeholders to work together to address the challenges posed by globalization and rapidly
changing social environments. For developing countries this is a priority as there is a vacuum in
mental health policy. A gap exists between those at the grassroots and those charged with the
responsibility to develop effective and equitable services. The situation is exacerbated for people
who have mental health problems and their families as they are further excluded from policy
processes by stigma, power differentials and lack of information. Methods: This paper reports
on five years of work and research by staff from an international mental health agency,
InterAction, in many countries including Estonia, Kyrgyzstan, Armenia, Bosnia, India and
Romania using the Pathways to Policy model. This model is theoretically based on policy-asprocess and public action concepts and has successfully enabled grassroots stakeholders,
including service users, carers, psychiatrists and members of local communities, to work together
to develop services and address local issues such as rural livelihoods, gender and transparency /
corruption. Results: The model has developed local and national policy forums that are run by
service users and other stakeholders. By providing the training, support and resources for these
grassroots lead forums, the model provides evidence that bottom-up approaches can build
partnership and collaborative activities based on mutual respect and trust. The research draws on
data including participatory analysis, semi-structured interviews, focus groups and reflective
records. Conclusions: By addressing the twin questions of how people at the grassroots can
shape mental health services and how they can have a voice in the policy debate, the paper
demonstrates that real outcomes are possible in countries where poverty, conflict and low
funding of services are common. The implications of this work are significant for the wider
development of mental health policy as it challenges accepted orthodoxies and indicates the need
for more inclusive responses to the problems of long term mental health needs.
Key words: Policy / Participation / User Involvement / Globalization
2.
Development of a European Measure of Best Practice for People with Long Term Mental
Illness in Institutional Care (DEMoBinc).
Helen Killaspy
University College London (for the DEMoBinc group)
43
Objective: The DEMoBinc project aims to develop a toolkit for assessing the living conditions,
care and human rights of people with long term mental illness in psychiatric and social care
institutions in European countries. The study has been funded for 36 months by the European
Commission and involves eleven centres across ten countries: UK; Germany; Spain; Czech
Republic; Bulgaria; Italy; Netherlands; Poland; Greece; Portugal. Methods: The toolkit will
constitute measures of domains considered most important for recovery. The domains are
currently being identified through an international literature review and Delphi exercises in each
country with mental health professionals, clients, carers and advocates. The domains will be
agreed by the research partners and an international panel of experts in rehabilitation and
recovery. Cross-cutting themes will be included to assess the institution’s promotion of its
clients' human rights. The toolkit will be refined through the course of the study to maximise a)
its reliability b) its usability c) its ability to deliver assessments that translate into action plans
within each country’s established systems of change at local, regional and national level. Data
will be collected to carry out a health economic analysis of its ability to provide information that
can be used to assess the institution’s “value for money”. The toolkit will also be cross-validated
against clients’ quality of life, autonomy and markers of recovery to test whether it can deliver a
proxy-measure of the promotion of individuals’ human rights and recovery. Results: Three
further session submissions (Tatiana Taylor, UCL: Professor Andrzej Kiejna, Wroclaw,
Poland; Dr Chris Wright, Penny Turton, St George's University London) will report findings
from Phase 1 of the project.
3.
Development Of A European Measure Of Best Practice For People With Long Term
Mental Illness In Institutional Care (Demobinc): A Delphi Study To Elicit The Opinions Of
Key Stakeholders;
Christine Wright, Penelope Turton, Sarah White, Helen Killaspy1
St George’s University of London,
1
University College London
Objectives: This is one of a group of presentations deriving from phase 1 of the DEMoBinc
project. Its particular aims were to a) to identify and b) to measure consensus on the domains of
care considered by key stakeholders across 10 European countries to be most important in
promoting recovery for people with long-term mental illness in institutional care. Methods:
Each participating country completed a three-round Delphi exercise. Each invited the opinions of
four separate groups of experts; service users, mental health professionals, carers and advocates.
In Round 1 an initial open question asked respondents to identify up to 10 components of care
they considered the most important in promoting patient recovery. In Round 2 these ideas were
fed back to the whole group, to be rated on a 5-point scale for their importance. Finally in Round
3 the group re-rated the components in the light of information about the whole group's response.
Where there was high consensus on components being ‘essential’ or ‘very important’ to
recovery, they were grouped into domains by CW and PT. These domains, together with
domains identified by the literature search, were agreed by the research partners. In consultation
with an international panel of experts in rehabilitation and recovery, they were then used to form
the basis for developing a toolkit to evaluate recovery- based practice. Results: Results will be
presented descriptively to show the domains and components of care considered to be most
important to recovery, and to show consensus within and across countries, and between
stakeholder groups.
4.
The Delphi Exercise in Poland
Andrzej Kiejna, Adamowski T, Ciałkowska M, Piotrowski P, Rymaszewska J.
Department of Psychiatry Wroclaw Medical University
44
Objective: The Delphi exercise carried out in Poland constitutes an example of the within
country Delphi exercises conducted in ten participant countries of the DEMoB.inc project funded
by the EC. The Delphi exercise aims to identify the most highly cited components of care that
contribute to the recovery of people with long term mental health problems residing in
institutions. Methods: The Delphi approach has not been widely applied in Polish research. The
method is characterized by the following features: a defined group of expert participants;
information flow; regular feedback; and participants’ anonymity. The Delphi method has
enormous potential in many fields including health care, social sciences, new technologies and p
olicy forecasting. However the reported disadvantages include: the informality of the selection of
experts; the use of basic statistical methods; and the inability to make complex forecasts with
multiple factors. In addition, there tends to be decreasing response rates to subsequent “rounds”
of Delphi questionnaires. We carried out a three stage Delphi exercise with 12-15 participants of
each of four expert groups (service users, mental health professionals, carers and advocates). We
sought a wide range of representatives in each group to promote diversity in responses. Results:
There were problems with maintaining contacts with participants due to their geographical
spread across the country, and few had e-mail or mobile phones. However, we will be able to
report final results by March 2008. So far, convergence in response across countries appears
good. Out of 11 identified domains of care, only two (social policy, human rights and advocacy
and self management and autonomy) were not consistently cited.
5.
Components of institutional care for adults with longer term mental health problems:
A systematic review.
Tatiana Taylor, Helen Killaspy, Michael King
University College London
Objective: As part of the DEMoBinc (Development of a European Measure of Best Practice for
People with Long Term Mental Illness in Institutional Care) study we carried out a systematic
review of the literature published in peer reviewed journals since 1980 to (1) identify the
components of care in institutional care settings for people with longer term mental health
problems, (2) assess the evidence for outcomes associated with these components and (3) use the
best available evidence to assist in identifying the domains of institutional care most important in
promoting recovery for inclusion in the DEMoBinc toolkit. Methods: A search of eleven
relevant electronic databases was conducted for articles relevant to the study aims. All articles
were screened for eligibility. Included stud ies were assessed for quality and relevant information
was extracted for analysis. Domains were determined once all data was compiled. Results: A
total of 8,628 possibly relevant articles were identified through the search strategy. One hundred
and seven studies met the inclusion criteria and were included in the review. Although the
majority of studies came from the USA and UK, relevant studies from across Europe (The
Netherlands, Greece, Spain, Italy, Switzerland, Finland, Germany, Austria, Norway, Poland, and
Sweden) as well as Australia, New Zealand, Canada, Japan, China and Brazil were included. Ten
domains were found to be associated with the quality of institutional care: Living Conditions;
Treatments; Physical Health; Restraint and Seclusion; Therapeutic Relationship; Autonomy;
Service User Involvement; Staff Training and Support; Clinical Governance; and Recovery.
6.
Sensitivity for ethnicity and gender issues in mental health organizations
Mojca Urek, Shulamit Ramon
University of Ljubljana, Faculty of social Work
Faculty of Health and Social Care, Anglia Ruskin University, Cambridge, UK
45
Objective: The Emilia project (EU-FP6) is an action research aimed at enhancing the social
inclusion of people experiencing severe mental distress within eight demonstration sites across
the Europe, by focusing on education and employment opportunities. One of the objectives of
the project is to improve the mainstreaming of gender and ethnicity within the sites, as lack of
such mainstreaming adds to the already existing barriers towards social inclusion. Methods:
Thus far, we went about achieving this objective by:
1. commissioning a wide ranging report on EU mainstreaming policies and actions;
2. obtaining updated data from staff members on issues related to ethnicity and gender in their
workplace and their relevance to work with service users;
3. based on the findings, each site had to construct its action plan for mainstreaming.
We are currently obtaining data from service users. Results: Service providers mostly feel that
discrimination is caused by society at large, rather than by them, and that therefore there is very
little that they can do about it. The reality is that mental health services work with people who
have been largely victims of discrimination and at times of abuse, who know only too well that
no-one wants to know about this type of experience. Lack of sufficient training pertaining to
ethnicity and gender has been identified by the most of the sites as an issue to work on within
their action plans. Conclusions: The variability in national laws and policies already in place,
sensitivity, knowledge and attitudes to ethnicity and gender issues within the sites poses a
considerable challenge within the Emilia project, which has to be tackled while respecting the
sites’ uniqueness.
XIII. INSTRUMENTS AND METHODOLOGY
1.
Lost In InterpretationUsing interpreter in qualitative research
Karin Ingvarsdotter1, Sara Johnsdotter2, Margareta Östman3
1
PhD student Health and Society; 2PhD Social Anthropology 3Ass. Prof.Faculty of Health and
Society, Malmö University, Sweden
Objective: There is a growing interest and demand of research on ethnic minorities and
consequently more scholars have to deal with issues concerning research with interpreter. Even
if the amount of literature on the topic is increasing most books and articles continue to focus on
modes of procedures, recommending rigorous techniques. The primary focus of this article is the
identification and exploration of important aspects that the role of interpreter in research arouses.
Method: From a research project concerning perception of mental ill-health in a multicultural
neighbourhood in Malmö, Sweden, two unstructured interviews undertaken with interpreter were
chosen fo r a second translation. The interviews were chosen out of the feeling that one was
successful while the other was more or less a disaster. All Swedish was cut from the audio files,
independent translators worked with the conversation between the interpreter and informant and
delivered a second transcription. Moreover follow-up interviews with two independent
interpreters were conducted. Result: Four important aspects crystallized in the analysis of the
role of interpreter in qualitative research. These are: the correlation between epistemological
framework and view of the interpreters’ role in research; the value of the researchers’ intuition
which is often underestimated in research contexts; the language and coherence systems and the
importance of metacommunication; forgotten aspects overthrowing recommendation in
contemporary literature. Conclusion: The results illustrate the importance of being explicit in the
description of methodological issues concerning the use of interpreter. Concurrently with the
increasing interest in cross-cultural research the discussion concerning interpreter in research
needs to be lifted to another level and new aspects need to be taken into consideration.
2.
“CAN”as tool in long-term community based treatment”
46
Jerker Hanson, Marie Askerstam1, Helena Forslund2
1
Psychiatric Clinic, Södertälje Hospital; 2Social Services, Södertälje Municipality, Sweden.
Objective: Evaluate the use of"Camberwell Assessment of Needs, CAN" as aninstrument in
longterm treatment and care of persons with severe mentalillness (SMI) in units with integrated
social welfare and psychiatric care and treatment. Method: CAN data have been collected yearly
for all patients with SMI in Södertälje catchment area (83 000 inhabitants) and used for
individual rehabilitation plans, revised yearly. 90 patients could be followed from 1997 to 2006.
Changes in needs were analyzed over time. Results: ”Unmet needs” decreased during the period
in 18 of 22 fields (especially close relations, emotional di sturbancies, serious psychiatric
symtoms, social contacts). The decrease in needs reported in treatment and physical health was
slight, indicating necessity for further activities in thes fields. There was a very slight increase in
four fields (personal care and house keeping, drugs and alcohol). Staff often rated needs higher
than patients especially regarding occupation, psychotic symtoms, nutrition. However, needs for
information about treatment was rated higher by patients than by staff. CAN forms were filled in
yearly by patient and his/her personal contacts from both the psychiatric clinic and from social
welfare, together. That made needs, symtoms, points of view and demands obvious and shared
be everybody involved. Through the years a learning process took place, important for a good
outcome, reflected in some of the ”needs” monitored. On a group level, results were used to
develop activities in fields with high needs and in the dialogue with decisions makers, purchasers
and politicians. Conclusions: Can is a useful tool for tailoring work with individual patients but
also for development of organization and for quality assurance.
3.
User participation in research
Bengt Svensson, Lars Hansson
Department of Health Sciences Lund University, Sweden
Objective: To investigate consumer satisfaction with psychiatric services by using other
consumers as interviewers. The study was made in 2005 and replicated in 2007. Method:
Twenty consumers where recruited to attend an educational programme for becoming
interviewers. After completing the education they performed interviews where they administered
a questionnaire with nine items and made a qualitative interview based on three themes: “What
have been most appreciated in the care, what have given most negative feelings in the care given
and what is in most need for change?” Finally, after the completion of the data collection focus
groups were made with the interviewers. The qualitative data was analysed with content analysis.
Results: In 2005, 227 patients were interviewed and in 2007, 211 patients participated in the
study. The main findings were that a majority of the patients experienced a high satisfaction with
care as measured with the questionnaire but in the qualitative part of the study they expressed
significant dissatisfaction with many aspects of the treatment. The focus groups showed that the
interviewers found the interviews inspiring and fun to do and that they felt it contributing and
interesting to talk to the patients. Some, however, felt burdened by the case histories they took
part of during their work. Conclusion: It was possible to recruit users for participation in a
research project. It was also possible to make a design where user interviewers with a minimum
of training performed interviews with patients in both inpatient and outpatient settings in order to
collect systematic data.
4.
Do We Need A Patient Preference Randomised Controlled Trial? Findings From A Patient
Preference Randomised Controlled Trial Comparing Women’s Crisis Houses And
Psychiatric Hospital Inpatient Admissions
47
L. Howard1, L.Cole1, S.Byford1, M. Leese1, J.Betts2 and S. Johnson2
1
Health Service and Population Research Department, Institute of Psychiatry, London, UK;
2
Department of Mental Health Sciences, University of College London, London, UK
Objective: To establish the feasibility of a patient preference randomised controlled trial study
design for investigating the effectiveness and cost effectiveness of women’s crisis
houses. Methods: Women assessed for an admission to an acute psychiatric inpatient ward or a
women’s crisis house in 3 London boroughs during a 6-month period in 2007 were asked
whether they would be willing to take part in a randomised controlled trial and their strength of
preference for the service they preferred was measured. Women who were not willing to be
randomised but willing to participate in a study were allocated to their preferred service choice
where possible. Patients were followed-up 3 months later. Results: Over the 6-month period,
450 women were eligible for the study and 103 were recruited. 8 patients were recruited in the
community, 56 on the ward and 39 at a women’s crisis house. 61 patients entered into the patient
preference arm of the study (37= women’s crisis house and 24=psychiatric hospital ward) and 42
women were randomised. 85% of participants obtained their allocated or preferred treatment
site. Conclusions: Most women did not want to be randomised. This suggests that patient
preference randomised controlled trials may not be a useful alternative to a randomised
controlled trial in some health services research.
5.
The Velo Study – Relations Between Organization Of Mental Health Services And
Treatment Philosophy.
Svein Bjorbekkmo1, Reidun Olstad2, Lars Henrik Myklebust3, Knut Sørgaard4
1
The Nordland Hospital Vesterålen, Stokmarknes,2,3 Psychiatric Research Centre of North
Norway, University Hospital of North Norway, Tromsø,4 Psychiatric Research Centre of North
Norway, University Hospital of North Norway, The Nordland Hospital, Bodø
Objective: This study is a part of the VELO study – A comparative study of two Community
Mental Health Centres (CMHC) in Northern Norway. The CMHCs are organized differently
with one having no local inpatient unit, the other having three. Both CMHCs use the Central
Mental Hospital situated rather far away for compulsory and other admissions. Consequently, the
main difference between the two centres is the use and localization of beds. The central
hypothesis for the VELO study is that available resources for treatment have impact on the
treatment given for various psychiatric conditions, resulting in different treatment for similar
patients at the health systems. The present part of the study focuses on the impact of the ward
staffs level of competence and the philosophy of treatment in the two CMHCs and the central
bed units on treatment mode. Methods: 252 clinicians and ward staff at the CMHCs and the
cental bed units answered two questionnaires on clinical practice: one with questions about
formal education, work experience and clinical orientation; the other with questions about the
philosophy and practice at the unit. An extended version of Community Program Philosophy
Scale (CPPS) was used. Results: We found significant differences between CMHC inpatient
units and central bed units concerning competence. We also found differences in emphasis on
kind of and length of treatment and in emphasis on cooperation with other instances.
Conclusions: The results indicates that there are significant differences in competence and
treatment philosophy between local bed units and central bed units that may contribute to
differences in treatment mode for patients with similar psychiatric problems from the two
catchment areas.
48
XIV. BEYOND VERBAL INTERVENTION
1.
The effects of Basic Body Awareness Therapy in Psychiatric out-patient care
Amanda Lundvik Gyllensten
Basic Body Awareness Therapy (BBAT) is a treatment intervention used within Psychiatric
Health Care in Scandinavia. The treatment is based on movements in walking, standing, sitting,
lying position together with a mindful awareness in the present moment.
In a randomised controlled study in Psychiatric outpatient care 77 patients with anxiety,
depression or personality disorder and bodily symptoms were randomised to treatment as usual
(TAU) or TAU and 12 sessions with BBAT. In the treatment group there were 38 patients and in
the control group there were39 patients. There were no significant differences as to diagnostic
and sociodemographic data at baseline. Nor were there any significant diffrence in any of the
primary outcome measures, The Body Awareness Scale- health (BAS-H) or the BAS- Interview
at baseline. Other instruments used in data collection were the Symptom Checklist 90, the Sense
of Coherence, Nottingham health Profile, Arthritis Self-Efficacy Scale and Coping resources
Inventory. After a 3 month treatment period, the treatment group had significantly improved
body awareness, balance, coordination and less muscle tensions (p<0.001). They had an
improved attitude to the body and their symptoms (p<0.001) as well as an improves self-efficacy
(p<0.05). At the six- month follow up, the treatment group still were significantly improved
concerning the same variables. A study of the use of psychiatric healthcare and the social
insurance system during a 12 month period starting at baseline, revealed the treatment group to
have a significant less use of psychiatric health care and total use of social insurance (p<0.05).
2.
The therapeutic theatre on the way to recovery
Anna Bielańska
Community Psychiatry Unit, Chair of Psychiatry, Jagiellonian University, Krakow.
Drama therapy is one of the elements of the complex treatment for schizophrenic outpatients in
the Psychiatry Department in Cracow, Poland. The use of drama therapy in the treatment of
schizophrenic outpatients may be considered as a combination of psychotherapy and social skills
training that allows patients to obtain a greater understanding of their emotional selves in relation
to others. The aim is to present the therapeutic theatre as the means of a special kind of therapy
which can lead to recovery. The authors describe some healing factors in the process of drama
therapy: structure, creativity, fun and the involvement of a professional theater director. The
results such as better self-expression, communication and social competence was found and
reported after one to three years of drama therapy. The most difficult aspect is to transfer the
experience gained in therapeutic theatre to their „real” lives.
A short 5 min DVD film will be presented.
3.
Could Dramatherapy Improve The Ability To Recognize And Express Emotions For
Patients With Schizophrenia?
V. Sippel, S. Berg, F.-M. Sadre-Chirazi-Stark
Asklepios Westklinikum Hamburg, Germany
Objective: Impaired emotional communication may be an important contributing factor to poor
social functioning in schizophrenia. This research aimed to evaluate the effects of a drama49
therapeutical manual for schizophrenic patients. Methods: Patient were there own controls in a
within-subject-investigation. The expected improvement of emotion recognition and expression
in 32 outpatients were investigated by following three outcome criteria: 1. Patients evaluated the
emotional content by standardized picture material (Ekman & Friesen), the scanpaths by tracking
the pictures were sampled by using an eyetracker 2. Patients imitated the emotions expressed on
the picture material and the level of congruence with the stimulus material was measured by
means of a standardised coding system (FACS). 3. The changes in patients’ negative symptoms
was documented by using Positive and Negative Symptom Scales and Calgarys’ Depressions
Scale. Results: It could be shown that the manual was applicable for the use with patients, and
patients showed high significant improvement in negative symptoms, in symptoms of depression
and in social functioning after completing the drama-therapy in comparison to their baseline. The
improvement did correlate to a normalisation of the scanpath by tracking the faces with
emotional expression. Conclusion: Drama therapeutic approach could play a crucial role in
improvement of social cognition in deficits of social cognition in negative symptoms of
schizophrenia.
4.
The cost-effectiveness of group therapy in community mental health services
Barbara Barrett, Sarah Byford
Objective: The high cost of individual psychological therapies makes group-based delivery
attractive. However, evidence on the cost-effectiveness of these group therapies is scarce. Here,
we report the results of two randomised controlled trials of group therapy for depression in adults
and repeated deliberate self-harm in adolescents and identify issues and factors that influence the
cost-effectiveness of group cognitive behavioural therapy in community services. Methods: In
the first study adults with depression were randomised to group mindfulness-based cognitive
therapy or maintenance antidepressant treatment and followed up for 15 months. The costeffectiveness analysis measured costs to all service providing sectors plus productivity losses and
outcomes in terms of depression relapses. In the second study, adolescents with repeated
deliberate self-harm were randomised to group cognitive behavioural therapy or treatment as
usual. Here the cost-effectiveness analysis measured costs to all service providing sectors and
outcomes in terms of the number of self-harm events. Results: In the first study, relapse rates
among those randomised to mindfulness-based cognitive therapy were 13% lower than
maintenance antidepressants, though this difference was not significant. There was no difference
in average cost between the two groups. In the second study, there were no differences in
outcomes between those randomised to group cognitive behavioural therapy and usual care. The
results of the economic evaluation will be reported at conference. Conclusions: Despite having
lower costs than individual therapies, group psychological therapy is not necessarily more costeffective.
XV. STIGMA AND MENTAL ILLNES 2
1.
Changing Medical Education: Results Of The Anti-Stigma Training And Evaluation
Collaboration (Astec) Trial
Aliya Kassam, Nick Glozier, Morven Leese & Graham Thornicroft
Institute of Psychiatry, King’s College London
Objective: To evaluate changes in knowledge and attitudes in third year medical students at a
medical school in South East London before and after they received training on stigma and
discrimination of people affected by mental illness. Methods: Training was delivered by the
50
mental health charity Rethink to students during their two week introductory session in
September 2006. Students’ knowledge and attitudes were assessed at baseline and after training.
This was a controlled trial with three conditions. The control condition received the standard
introductory training. The lecture only condition received a lecture of key information about
stigma and discrimination against people affected by mental illness along with personal
testimonies from a mental health service user and carer of a person with mental illness. The
lecture and role-play training condition received the lecture as well as role-play training
involving communicating with role-players who were carers and service users. The role-play
training involved service user and/or carer feedback on the students’ performance regarding their
verbal and non-verbal communication skills. Results: Medical students mainly had positive
attitudes towards people affected by mental illness at basel ine. Favourable changes in attitudes
and knowledge were detected in the lecture and role-play training condition compared to their
scores at baseline. Favourable changes in knowledge were also detected in the lecture only
condition compared to their scores at baseline. Conclusions: In order for positive changes in
attitudes and knowledge pertaining to mental illness and people affected by it to occur in future
doctors, the medical education curriculum needs to change. Medical students not only need
lectures addressing knowledge and attitudes but training in communicating with people affected
by mental illness.
2.
Is there age-related inequality in the use of mental health services in the UK?
Roshni Mangalore1 & Martin Knapp2
1
Personal Social Services Reserach Unit, 2London School of Economics, Houghton street,
London UK.
Objective: To see if there is age discrimination in the use of mental health services that is
unfavourable to the older people in the UK. Methods: Data from a longitudinal observational
study of about 600 patients suffering from mental health problems is used in order to test
whether older people receive mental health services in proportion to their needs. Multivariate
analysis is conducted to examine if use of services during a six-month period is influenced by
age when all other factors influencing utilisation are controlled for. Robust estimates are
obtained using bootstrap method to correct any bias in the sample. Results: Results show that
age is a significant factor in determining use of mental health services. Negative correlation of
age with total use of services suggests that older patients use less service than the younger, given
their psychopathological conditions and other factors that influence utilisation of services. There
appears to be age-related inequality in the use of services. Conclusions: There is a need to
address the needs of older mental health patients as they do not receive services in proportion to
their needs.
3.
Attitudes towards people with mental illnessa cross-sectional study among nursing staff in
psychiatric care and somatic care
Tommy Björkman, Therse Angelman, Malin Jönsson.
Department of Health Siences, Lund University, Sweden
Objective: In efforts to reduce stigma and discrimination, health professionals play an important
role as they have frequent contact and responsibility for treatment and rehabilitation of
consumers. The aim of the present study was to investigate attitudes towards mental illness and
people with mental illness among nursing staff working in psychiatric or somatic care. Methods:
With a cross-sectional design a sample consisted of 120 registered or assistant nurses were
interviewed about intimacy with mental illness and attitudes about seven different mental
illnesses. Results: The results showed that nursing staff in somatic care, to a higher degree than
51
nursing staff in mental health, reported more nega tive attitudes with regard to people with
schizophrenia as more dangerous and unpredictable. In contrast, professional experience,
intimacy with mental illness and type of care organization were found to be more associated with
attitudes to specific mental illnesses concerning the prospect of improvement with treatment and
the prospect of recovery. Conclusions: In conclusion, attitudes among nursing staff are in
several respects comparable to public opinions about mental illness and mentally ill persons. In
order to elucidate if negative attitudes about dangerousness and unpredictability of persons with
specific mental illnesses are associated with realistic experiences or with prejudices further
studies with a qualitative design are suggested.
4.
Staff’s experiences and understanding of support to abused women with mental illness
Bengtsson-Tops Anita
University of Växjö, Sweden, Department of Caring Sciences and Social Work
Objective: Several studies have reported that care and support staff has a tendency to ignore
recognising violence against women with mental illness, which lead to increased feelings of
stigma in these women. Today there is a lack of in-depth knowledge about factors that may
influence care providers attitudes in encounters with these women. The aim of this qualitative
study was to describe how staff experience and understand their everyday work with abused
women with mental illness. Methods: 13 professionals who in their working practice
encountered women with mental illness and experience of abuse were interviewed by means of
unstructured thematic interviews. Data were analysed by using latent content analysis in order to
identify categories a nd themes. Results: Participating staff found it hard to understand abuse
against women with mental illness. They lack knowledge about how to handle and interpret this
phenomenon and developed personal frames of interpretations and strategies for handling the
women’s needs. They experienced their everyday work with these women as painful and
ambiguous and made them act pragmatic mainly in a practical way that sometimes included
assertive attitudes. Conclusion: Staff working with abused women with mental illness is in a
vulnerable position due to lack of understanding and knowledge about the phenomenon. In such
position it is at risk to adopt stigmatised attitudes against the women and thereby challenge the
professionals’ occupational safety.
5.
Gert Scheerder, Else Tambuyzer & Chantal Van Audenhove LUCAS
Tackling Mental Health Stigma: Evaluation Of Experiences In Belgium
Catholic University of Leuven, Belgium
Objective: The stigma of mental illness is still very common, with a deleterious impact upon
those affected. Evidence based action to increase mental health literacy and to fight stigma has
therefore been gaining interest. Belgium too has recently seen increased attention to this topic.
Particularly the installation of an umbrella organization to fight stigma, grouping and guiding
more than 50 local projects, has resulted in increased dynamics, a more systematic approach and
improved evaluation of such initiatives. We report on the evaluation of 3 of these projects, which
provide an account of the experiences gained in Belgium. Methods: The first study investigated
participants’ characteristics (n=2104) to 32 projects held in 2006 and 2007. The second explored
participants’ (n=76) satisfaction with the approach and the subparts of a public information event
on depression and suicide for adolescents. In the third study, we evaluated the effect of an antistigma intervention, including education and contact, on adult participants’ (n=106) attitude
towards mental illness, using the CAMI. Results: In the attendants to the anti-stigma projects
women, elderly and education and care sector professionals were overrepresented. Over 80%
already had some experience with mental health care, by knowing staff or patients, which was
52
the primary source of recruitment. In the second study, interactive elements and a testimony saw
the highest satisfaction scores. The third study’s intervention proved to be effective in positively
influencing attitudes on three CAMI scales: authoritarianism, social restrictiveness and
community mental health ideology. Conclusions: The experience with anti-stigma projects in
Belgium indicates that they can be effective in changing attitudes. To optimize their impact,
however, recruitment should focus on societal sectors outside health care and education
XVI. RESIDENTAL ALTERNATIVES TO INATIENT TREATMENT
1.
Acute Inpatient Wards And Residential Alternatives; A Quantitative Comparison Of
Service Users’ Experience And Satisfaction With Services
B.Lloyd-Evans1, S.Johnson1, D.Osborn1, H.Gilburt2, M.Slade2
1
Dept. Mental Health Sciences, University College London, UK,
Population Research Dept, Institute of Psychiatry, UK
2
Health Services and
Background: There is considerable service user dissatisfaction with acute inpatient psychiatric
wards. Community residential and innovative inpatient services form a significant but underresearched part of residential acute mental health care in the UK. Objective: To compare users’
satisfaction with services, perceptions of coercion and service atmosphere at UK standard acute
inpatient psychiatric wards and residential alternatives. Method: The Alternatives Study is a
national study evaluating the effectiveness and acceptability of community residential and
inpatient alternatives to standard acute inpatient services in England. Evaluation of clinical
outcomes is presented separately. To evaluate acceptability, four measures were completed with
service users at four alternative and four standard inpatient services (n = 320): two measures of
satisfaction with services – CSQ and SSS-RES; a measure of perceived coercion – AES; a
measure of ward atmosphere – WAS. Results: Data from the four measures will be reported and
comparisons of alternative and standard services presented. Conclusions: The acceptability to
service users of residential alternatives and standard inpatient services will be discussed and
implications for future service provision considered.
2.
Residential Care: Italian And Dutch Residents Compared
Charlotte de Heer-Wunderink, Annemarie D. Caro-Nienhuis, Sjoerd Sytema, Ellen Visser,
and Durk Wiersma
University of Groningen, University Medical Center of Groningen, University Center of
Psychiatry, the Netherlands
Objective: Characteristics and living conditions of patients with long term mental health
problems in residential care facilities have hardly been studied. Recently, the interest in this
subject has increased. This study aims to compare the characteristics and living conditions of
patients in residential care facilities in the Netherlands and Italy. The different
deinstutionalisation processes in these countries may have influenced the composition of these
residential populations. Methods: Data of the Dutch UTOPIA-study and the Italian PROGRESstudy were used. Results: The number of beds in residential care facilities in the Netherlands
appeared to be twice as high as in Italy (per 10,000 inhabitants). In the Netherlands, patients in
residential care facilities were more likely to abuse substances or alcohol, less likely to suffer
from schizophrenia, and to have a longer duration of stay despite their younger average age. We
expected Dutch residents who still have good access to long stay beds in mental hospitals to be
less disabled than Italian residents, but they were not. Conclusions: The results of this study
show that the different deinstitutionalisation processes in the Netherlands and Italy has led to a
53
difference in the number of residential beds that are available for patients in these countries.
Although we found some differences between Dutch and Italian patient characteristics, they did
not influence the overall level of functioning of both patient groups.
3.
Pathways to admission for women admitted to women’s crisis houses compared with
psychiatric wards
Louise Howard1, E. Rigon1, L. Cole1, C. Lawlor2, and S. Johnson2.
1
Health Service and Population Research Department, Institute of Psychiatry, London, UK;
2
Department of Mental Health Sciences, University of College London, London, UK
Objective: to compare the socio-demographic and clinical characteristics, and pathways to
admission for women admitted to women’s crisis houses with those of women admitted to
psychiatric hospitals. Methods: A questionnaire was completed by staff detailing women’s
admissions to an acute psychiatric inpatient ward or a women’s crisis house in 4 London
boroughs during a 12- week period in 2006. Results: In the multivariate analysis, female
admissions (n=278) admitted voluntarily to women’s crisis houses were significantly less likely
to have a care-coordinator or have gone to an Accident and Emergency department before
admission compared with voluntarily admissions to psychiatric wards. There were otherwise no
significant differences in the clinical and socio-demographic characteristics of the two groups or
in the complexity of the pathway to admission. Conclusions: There is little evidence to suggest
that women admitted to women’s crisis houses have significantly different pathways to
admission compared with women admitted to psychiatric hospital and there are few clinical or
socio-demographic differences between the groups. Future research needs to examine whether
women’s crisis houses are as effective as traditional psychiatric inpatient services in treating
women with acute mental health problems.
4.
The Alternatives Study – Residential Alternatives To Hospital In The Uk
Helen Gilburt1, Bryn Lloyd-Evans2, Sonia Johnson2, David Osborn2, Mike Slade1
1
Institute of Psychiatry, Kings College London, UK
2
University College London, UK
Background: As a result of the high cost of hospital care, discontent amongst both patients and
professionals with poor physical and therapeutic environments, and local innovations to deal
with people in crisis, a number of residential alternatives to hospital have developed in the
UK. Objectives: The Alternatives Study aims to investigate services offering different
residential solutions to hospital care for people with acute mental health problems in the
UK. Through an understanding of care pathways, the populations they serve and progress made
by patients during their admission, the team aims to discover whether these services offer a true
alternative to psychiatric hospital. Methods: Following a survey of acute residential services in
the UK a typology of alternative services was developed. Six services representing different
types were selected for further study. A consecutive cohort of 35 patients at each service was
followed from admission to discharge. Staff completed questionnaires detailing demographic
information, the patient journey, and brief ratings of clinical presentation, risk and social
functioning at admission and discharge. Results: We will describe the groups using the various
alternatives and compare them with users of standard services in terms of the nature and severity
of their clinical and social problems, service use histories and pathways through services. These
data will be used to assess the role of each alternative within its local service system and the
extent to which it is used by similar groups to traditional hospital care. Conclusions: We will
discuss the implications of these local innovations for service planning and re-evaluate the
beliefs and assumptions about what should constitute acute care for people experiencing crises.
54
5.
Anna Serafin1, Maria Załuska2
“PROGRESS” - model of holistic support of youth suffering from severe mental disorders - as a
element of psychiatric community care service.
1
MD, PhD, Mazovian Neuropsychiatri Center for Child and Youth in Zagorze near Warsaw.
2
Ass.prof. MD, PhD, IV Department of Psychiatry of the Institute of Psychiatry and Neurology in
Bielański Hospital in Warsaw.
Objective: There is no doubt that youth with severe mental disorders need special support. The
idea is to prevent their chronic status, marginalization and to increase their chance of entering the
open labor market. Usually youth with schizophrenia at the age of 18 they applied for a
disability benefit. This is really a deeply negative phenomenon and also very costly for the state
budget. PROGRESS. has been developed as a “ best practice” framework European Initiative
EQAUL. Project is compliant with the guidelines of the National Programme for Mental
Health Protection. Methods: The concept was inspired by the Danish experiences of support of
young ex-psychiatric patients. The model PROGRESS was created as a PROGRESS Center.
There are different types of support provided under "one roof": psychiatrie rehabilitation, support
in education and socialization. Special attention is paid to enrichment. Support is based on:
individual assistance and individual rehabilitation program. Results: Results will be presented
as a evalaluation of model. Outcomes, confirmed by scientific research, will be described from
individual, group and whole concept perspective. The Kidscreen-52 and others tools has
been used for collecting data. Conclusions :Systemic solutions in sociopsychiatry for youth are
needed and strongly recommended in Poland. The Project’s long-term plan foresees
development of a network of PROGRESS Centers. Model assumes: international network and
co-financing from diverse sources (health-, education- and social- sectors) The essence of the
Project is involvement in development of youth sociopsychiatry in Poland.
6.
Best Practices In The Provision Of Housing For Persons With Serious Mental Illness:
Where Do Consumers Want To Live?
Myra Piat, David Bloom, Richard Boyer, Alain Lesage, MD., Henri Dorvil
Montreal, Canada
Objectives: This presentation will report the findings of a recent study on housing preferences of
consumers with serious mental illness living in all types of housing in Montreal, Canada, and
compare these to the housing preferences of their case managers. The provision of decent and
affordable housing is one of the most important elements in integrating this population into the
community and is fundamental to their recovery. Without good quality housing successful
community integration is not possible. However access to long term stable housing remains
problematic and evidence-based research on housing for this population is lacking. Methods: A
stratified random sample of 336 consumers matched to their case managers evaluated their
housing preferences. Two questionnaires were administered: (1) Consumer Housing Preference
Survey and (2) Camberwell Needs Assessment. Results: Although many consumers prefer
living in their own apartment, it is not the overwhelming majority, as only 44 % expressed this
preference. The majority of consumers prefer living in housing that offers them more autonomy
than they are currently living in. Case managers prefer housing that offers some structure, such
as supervised apartments. More than a third of consumers prefer living in their current housing.
Conclusions: Although current policies favour autonomous housing for persons with serious
mental illness findings point to the need to take into consideration the viewpoints of mental
health consumers. A variety of housing, not just autonomous housing, is needed to meet the
specific housing preferences of individuals with serious mental illness. Implications for service
providers and mental health planners will be discussed
55
XVII. SOCIAL INCLUSION THROUGH WORK
1.
Service User Employee
Finn Blickfeldt Juliussen
The Danish Centre of Research and Information for Social Psychiatry
Headline: The Danish Centre of Research and Information for Social Psychiatry presents a 3year Rehabilitation project called ”Service User Employee.” The project included 109 people
holding educational backgrounds within social work and health care who had previously
received a psychiatric diagnosis. The aim was to improve the participants’ personal skills to
enable them to use their client background professionally as user employees with dual
competencies in the daily rehabilitation work in mental health services. Objective: The project
was focused on three basic assumptions as to the significance of the employees on a workplace:
1.Be important role models for recovery and help remove prejudices against people with mental
illnesses. 2.Facilitate a visible cultural integration of user perspectives within mental health and
social services. 3 Inspire managers and colleagues to a more rehabilitation-orientated
approach. Methods: The project comprises 5 vital components forming the framework for the
individual employee’s reintegration into the labour market: The combination of a customized
training programme and internship period. Individually adjusted follow-up, Networking between
service user employees, Ownership both at managerial, collegial and at service user level,
Cooperation between mental health, social and labour services. Results: 82 out of 109
participants completed the one-year rehabilitation programme. Based on the feedback from
managers, colleagues and service users pointing out numerous positive changes in daily practices
e.g. improved stress handling and development towards a more rehabilitating and inclusive
psychiatric approach. Conclusion s: The customized job creation model has proved its
applicability when it comes to helping service users gain and retain employment. Experiences
show that training, follow-up and collegial ownership together with a rehabilitation programme
of at least one year are essential. A follow-up enquiry of the importance of social networks with
regard to the success of the 82 participants is currently in the making. Plans hereof are available
for comments.
2.
Learning Potential And Rehabilitation Outcome In Schizophrenia: A Longitudinal Study
Stefan Watzke1, Peter Brieger2, Oliver Kuss3, Henning Schoettke4, Karl H.Wiedl4
1
Dept. of Psychiatry, Psychotherapy and Psychosomatics, Martin Luther University of HalleWittenberg, Julius-Kuehn, Germany. 2 Department of Psychiatry, Bezirkskrankenhaus
Kempten, Germany and University of Ulm, Germany. 3Institute of Medical Epidemiology,
Biostatistics, and Informatics. Martin Luther University of Halle-Wittenberg, Julius-Kuehn,
Germany. 4Department of Psychology, University of Osnabrueck, Osnabrueck, Germany.
Objective: The study examined whether a measure of learning potential is prospectively related
to the success of a vocational rehabilitation program for patients with severe mental illness in
Germany. Metho ds: At rehabilitation intake (November 2002 to January 2004), 41 persons with
schizophrenia or schizoaffective disorders completed a test-train-test version of the Wisconsin
Card Sorting Test as a measure of learning potential. Research participants were classified as
high scorers, learners, or nonlearners according to their WCST performance. Rehabilitation
outcome was assessed with measures of work capability during the rehabilitation program, level
of functioning during rehabilitation and at three-month follow-up, and level of vocational
integration at three-month follow-up. Results: Individual learning potential was associated with
the improvement of work-related learning ability during rehabilitation and with the level of
functioning and the level of vocational integration at three-month follow-up (about 15 months
56
after the initial testing). Generally, high scorers had better rehabilitation outcome at all
assessment points regarding all outcome measures. Even though learners and nonlearners started
at comparable levels at the beginning of the rehabilitation, learners benefited more from the
program, whereas nonlearners showed a rather unfavorable rehabilitation outcome. Conclusions:
Findings supported the assumption that learning potential is an informative predictor of
rehabilitation outcome and may add information beyond static cognitive measures. Learning
potential should be considered in the further development of vocational rehabilitation programs.
3.
Empowerment Of Mental Illness Service Users: Lifelong Learning, Integration And Action
Tamara Shaw
Institute of Psychiatry, King’s College, London
People with serious mental illness are among the most socially excluded members of our
society. Unemployment rates among people with schizophrenia are as high as 95%1. Because
people are socially excluded they have a reduced quality of life. Serious mental illness has a
substantial cost to society, in terms of state benefit payments and lost production through
unemployment. Objective: The EMILIA project will evaluate the efficacy of a lifelong learning
training programme across eight European demonstration sites. Our primary hypothesis is that
lifelong learning will increase the number of people with serious mental illness who are in
employment, compared to the previous year. Secondary hypotheses are that lifelong learning
will increase the time spent in employment or education, and thereby lead to an improvement in
quality of life. Methods: The research criteria for inclusion in the project are adults with serious
and enduring mental illness (schizophrenia and bi-polar disorder) who have had at least three
years’ contact with mental health services and who are without a ‘real world’ paid job. Outcome
data will be collected, in a repeated measures design, on employment status, use of mental health
services, amount of training received and quality of life. Service users will be assessed at
baseline (before commencing the EMILIA training) and at one year and two year follow up.
Data on the economic costs of the training interventions will be estimated from locally specific
information from the demonstration sites. Results: Preliminary findings from the baseline data
assessment will be presented. 1 Grove et al (2005); Perkins & Repper (2002)
4.
Social firms on the way to recovery
Igor Hanuszkiewicz, Andrzej Cechnicki, Anna Bielańska, Hubert Kaszyński
Community Psychiatry Unit, Chair of Psychiatry, Jagiellonian University, Schizophrenia
Research Group
The authors describe social firms as model projects which join several important elements of the
wide rehabilitation programme for people suffering from schizophrenia. The essence of
intervention in the mentally ill’s rehabilitation consist in ensuring their right to employment in
shaping their workplace so that they would be capable of performing their job. An important
goal is to promote and support special projects of work and employment - the social firms. The
social firm solution, a small hotel in the centre of Kraków has worked for five years and
employed 25 people with mental health problems. “U Pana Cogito” hotel started to function as
one of the many Kraków hotels and a part of the hotel infrastructure. Another social firms:
“Catering Cogito” and “Bicycle Rental Cogito” are the next projects, which has worked for one
year, and employ 20 people with mental health problems. The presentation ends up with 8min
film made by Polish television, were the perspective of employees is presented.
57
5.
From Exclusion To Inclusion? Evaluation Of Capital Volunteering
Sophie Bellringer, Abigail Easter and Joanna Murray
Institute of Psychiatry, London
Objective: Can volunteering contribute to increased social participation, social inclusion, and
rehabilitation? Capital Volunteering is a unique £7 million pan London program which aims to
tackle issues of stigma and social exclusion through volunteering. This presentation will discuss
the characteristics, circumstances and health status of 150 service users who joined Capital
Volunteering projects and their experience of changes in health, social inclusion and well-being
at three time points. Method: The evaluation used mixed methods to explore the process and
outcomes of volunteering. Interviews at the three time points included the same standardis ed
measures of: health and quality of life (GHQ, SF12, GAF); employment, household data and
service use (CSRI) and social networks, social capital and social participation (UK-RG, social
contacts). Participants were also asked open ended questions about their expectations and
experiences of taking part. Results: At six months 91% of participants said they had gained from
taking part in a volunteer project. These gains included: making new friends (29%); increasing
self-esteem (29%) and having somewhere to go and something to do (24%). At T2 there was
increased social engagement and wider access to social capital, for instance, a significant rise in
the number of reported friends and in particular friends outside of the mental health system.
Improvements in mental health and quality of life were also found. There were decreases in
service use and a significant reduction in the number of contacts made with a psychiatrist and in
the mean costs arising from these contacts. Conclusion: Results suggest there were
improvements in various domains of social exclusion such as widening of social networks and
access to social resources within this cohort. Self-reported benefits of volunteering include
improved confidence, skills and knowledge.
XVIII. TREATMENT IN COMMUNITY
1.
The Effects For Therapeutic Communities Of Changes In The Structure And Funding Of
Uk Psychiatric And Care Services
John Gale
CEO Community Housing and Therapy (CHT),
Objective: This paper is a presentation of the work of CHT, a voluntary sector provider of
therapeutic community environments in the UK for pychosis. CHT is a leading member of the
Community of Communities programme at the Centre for Quality Improvement at the Royal
College of Psychiatrists, the ATC and ISPS (UK). Methods: Three quantative research
instruments are in use – the WAS in its revised COPES format, the Good Milieu Guide and
HoNOS. Current research with Nottingham University aims at the design and implement of a
naturalistic analysis of clinical outcomes. The following scales have been introduced: RESPPI
aiming to capture all the features of the treatment environment; WAI reflecting the strength and
nature of the therapeutic alliance; SCID I, a structured clinical interview for ascertaining the
presence of DSM Axis I disorde rs; BoSI, a questionnaire designed to provide an assessment of
borderline traits and psychopathological distress and CORE. Outcomes: In 2006-07 the number
of people treated was 139. A further 64 have been accepted for extended assessment periods.
Results: 40% of patients moved to permanent and independent accommodation; 52% to less
supported accommodation; 69% of current patients are involved in activities in the community;
21% are in employment; 21% started voluntary work; 20% attended Day Centres; 37% attended
58
training courses. Conclusions: This is a case example of an innovative organisation which is
adapting to the changing culture and funding environment in psychiatric and social care
provision, through embracing evidenced based perspectives.
2.
The aviles model as a guide for implementing the assertive community treatment in spain.
Juan José Martínez Jambrina
Spain
Assertive Community Treatment (ACT) is a well-dened servicedelivery model for the care and
treatment of the most severely mentallyill people (SMI) in the community. An ACT team is a
multidisciplinary team which provides assertive outreaching intensive care and treatment to a
group of persons with severe mental illnesses. The Assertive Community Treatment team of
Avilés (Asturias, Spain) was the first ACT service-delivery model implemented in Spain. It
started in 1999 as an effort to give an answer to the increasing needs of patients with the most
severe and persistent mental illnesses and their families. Due to lack of previous communitybased programs following ACT model in Spain, our development process and start-up procedure
have guided a number of similar teams all over our country. This lecture will specially focus on
conceptual basis of our practice, staffing, organization and services provided in our area. Recent
outcomes from our team will also be presented.The speaker will briefly introduce the historical
background of "the Aviles Model" implementation and changes involving the existing practice of
classical community mental health services. Several conceptual issues including both society and
health professionals reactions to the model will also be discussed.
3.
Assertive community treatment vs. standard treatment for severe psychotic illness in
Denmark: a quasi-experimental trail.
Marie Høgh Thøgersen
Denmark
OBJECTIVE: To compare outcomes of care from assertive community treatment with care by
community mental health teams for people with serious mental illnesses in Denmark.
METHODS: non-blind quasi-experimental multi-centre trial including 366 long-term severely
mentally ill men and women with recent high use of inpatient care and difficulties engaging with
community mental health services, comparing treatment from assertive community treatment
(ACT) (n = 213) or continuation of care from standard treatment (ST) (n= 153). The primary
outcome was contact with mental health services. Secondary outcomes included, days of
admission, days of involuntary admission, adherence to antipsychotic medication, social
functioning, user satisfaction and psychopathology. RESULTS: ACT was significantly better in
sustaining contact. At two- year follow-up 7.5% of participants in receiving ACT treatment had
lost contact vs. 14% in standard care, (P = 0.03, df (1), OR 2.1 (1.1 to. 4.1). Participants who
received ACT treatment had fewer days of admission at two-year follow-up,(difference in means
20.1, 95% confidence intervals - 0.03 to 42), increased adherence to antipsychotic medication
(change in proportion taking +10% vs. +0.8%, P = <0.01), better social functioning (GAF
difference in means 3.3, 95% confidence interval - 0.9 to 5.8,), and a higher user satisfaction
(client satisfaction questionnaire difference in means 2.36, 95% confidence interval - 0.6 to 4.1).
No differences in days of involuntary admission, psychopathology, or quality of life were found.
CONCLUSIONS: This study finds that ACT improved engagement with services and user
satisfaction. Our study contradicts findings that ACT alone is not sufficient to reduce use of bed
days, improve social functioning and increase adherence to antipsychotic medication in a modern
psychiatric context.
59
4.
Assertive Community Mental Health Service In Tiblisi (Georgia)
Zavradashvili N., Donisi V., Grigoletti G., Gelashvili K., Eliashvili M., Amaddeo F.
Section of Psychiatry, Department of Medicine and Public Health, University of Verona, Italia
Georgian Association for Mental Health, Tbilisi, Georgia
Objective: In Georgia, socio-economic crisis has resulted in a drastic decrease in government
financing for Health. State Mental Hospitals continue to be the main solution for mentally-ill,
because of severe lack of community-based services. This study evaluated an experimental
intervention of assertive community care implemented in a district of Tbilisi, Georgia. Methods:
Inclusion criteria were age from 18 and 65 years, diagnoses of schizophrenia, having basic living
skills, no comorbidities with drug abuse and alcoholism, lack of contact with psychiatric
outpatient facilities and lack of social contacts. The intervention lasted 10 months and consisted
of telephone calls, visits at home, ambulatory visits, meetings outside services’ facilities; all s
ervices were provided by a multidisciplinary team. The Scale for Assessment of Positive
Symptoms (SAPS) and the Scale for Assessment of Negative Symptoms (SANS), the number of
hospital admissions and adherence to treatment have been assessed pre and post intervention.
Number, type of contacts and their costs were collected for the 10 months. Results: The 10
months follow-up period and psychopathological scale were completed by 26 subjects. Results
showed a significant reduction from baseline to 10-months in psychopathology as assessed by
SAPS (p<0.001) and by SANS (p<0.001), in the number of hospital admissions (from 11
admissions to 2 admission) and improvement in adherence to treatments. In the 10 months of
experimental intervention, the patients included have had 591 contacts with the team (22.73
contacts per patient). Estimated cost for the all time of intervention was 2,167.3 Euro (83.36
Euro per patient). Conclusions: Results showed the economic sustainability of community care
and its effectiveness.
5.
Independent Living in the Community after Prolonged Hospitalization.
Bert-Jan Roosenschoon, Arina van der Kwaak & Moniek Bogaards
Rotterdam, Netherlands
In Bavo Europoort (Rotterdam the Netherlands) there is a group of prolonged hospitalized clients
with a severe mental illness that could live outside the hospital if there are good alternatives for
hospitalization. The institute for sheltered living (RIBW) doesn't give them admittance because
of the danger of relapse. The RIBW cannot handle psychiatric crises and people with conduct
problems. This is a group of clients that is too well for the clinic, but not well enough for the
RIBW. Because of this they had to stay longer in hospital than necessary. There should be a
good alternative for them. Therefore Bavo Europoort in cooperation with housing corporations
hired some appartments so that they could live indepently, on their own or together with another
client. We did a program-evaluation on this project and report about it. They still get
intensive psychiatric homecare from Bavo Europoort and also guidance on living from some
other health care organizations. The amount of care is flexible and depends on their needs.
Sometimes they get home visits every day, sometimes only once a week. Everytime the
caregivers keep in touch with the clients. They keep a finger on the pulse.
Besides, many of them use facilities of the clinic, e.g. for eating, bathing, day-activities and
playing the piano. So for most of them there still is a strong connection with the hospital. There
is not much integration in the community. Now 26 clients have entered such an appartment; 21
of them succeeded to live indepently until now. Bavo Europoort should like to expand this form
60
of care. One could say that this type of care corresponds to the model of Assertive C ommunity
Treatment (ACT). However, care for this 21 clients is mostly given by 3 experienced psychiatric
nurses only and not by a multidisciplinary team with a 'team-approach'. Another big difference
with the clients of the ACT-teams of Bavo Europoort seems to be that ACT-clients mostly don't
have a history of long hospitalization. They mostly live on their own and have had only short
episodes of clinical crisis-intervention. In this presentation we explore similarities and
differences between 'Living in the Community' and ACT and suggest that the ACT-model could
be fruitful in this project.
POSTER PRESENTATION
1.
Patients Trust in Psychiatrists
Richard Laugharne, Greg Mather, David Baker
Cornwall Partnership NHS Trust, Trevillis House, Lodge Hill, Liskeard, Cornwall, UK
Background:Trust is a key factor in the quality of the doctor-patient relationship. In psychiatry,
the interaction between doctor and patient is often an integral part of the treatment itself. General
medical and primary care patients have been shown to trust their doctors but the same is not
known for mental health patients. This study aimed to compare patients’ trust in their
psychiatrists with that of their GPs and estimate the association with age, gender, continuity of
care, admission and compulsory detention. Method: A questionnaire was completed by
83 community mental health team patients in Cornwall which included the Trust in Physician
scale for their psychiatrist and their general practitioner. Patients were also asked about their
age, gender, length of association with the doctor, any history of admission to a psychiatric
hospital, and detention under the Mental Health Act. Results: Mental health patients have good
and almost equal levels of trust in both their psychiatrists and their GPs. Neither prior admission
to a psychiatric hospital nor detention under the mental health act altered their degree of trust.
There is a positive association between trust and the length of time associated with both groups
of doctor. Being older was associated with higher trust, independent of length of relationship
with the doctor. Females trust psychiatrists significantly more than males but gender has no
significant effect on patients’ trust for their GPs. Conclusions: Psychiatrists are as well trusted
by their patients as their GPs. Admitting and detaining patients under the mental health act does
not adversely affect trust nor does it appear to lead to improved trust. Continuity of care is
important in the development of trust in psychiatrists as it is for GPs.
2.
Correlation of “patients` satisfaction” and “doctor-patient relationship” in two mental
health services
Bletsa Dimitra, Kallinikou E, Dimakopoulos G, Koutsosimou M, Mavreas V.
University of Ioannina, Department of Psychiatry, Greece
Objective: Study of the correlation of "patients' satisfaction" and "doctor-patient relationship" in
two community based mental health services. Methods: The study involved 11 doctors and 193
patients (81 men, 112 women). Two dimensions of the VSSS-54, Doprac 16 and a doctor-patient
relationship assessment analogue scale were used. Results: A significant correlation is observed
61
between "Overall Satisfaction" and "Doctor-Patient Relationship", using the analogue scale,
according to all tests conducted (Pearson Correlation, Kendall's Tau b and Spearman's Rho).
This result is also verified when using Doprac-16 instead. Greater satisfaction usually reflects a
better doctor-patient relationship. "Doctor-Patient Relationship", measured by the analogue scale
is also found to be significantly correlated to patients' satisfaction with "Mental health
professionals' skills and behavior" according to all tests. The "Doctor-Patient Relationship"
measured by Doprac 16 is significantly but less powerfully related to "Mental health
professionals' skills and behavior". Conclusions: The doctor-patient relationship is related to
patients' overall satisfaction with mental health services and especially with satisfaction with
professionals' skills and behavior. A better doctor-patient relationship contributes greatly to the
patient's s atisfaction and should be treated as a factor of great importance.
* The research project is co-funded by the European Union-European Social Fund (ESF) &
National Sources in the framework of the Program "PYTHAGORAS I" of the "Operational
Program for Education and Initial Vocational Training" of the 3rd Community Support
Framework of the Hellenic Ministry of Education.
3.
Factors affecting patients` satisfaction with mental health services
Kallinikou Eleftheria, Bletsa D., Dimakopoulos G., Koutsosimou M., Mavreas V.
University of Ioannina, Department of Psychiatry, Greece
Objectives: Study of the factors that affect patients' satisfaction in two community-based mental
health services. Method: The study involved 11 doctors and 193 patients. The instruments used
were: A socio-demographic form, two dimensions of the VSSS-54, DOPRAC-16, EPQ and a
doctor-patient relationship assessment analogue scale. ANOVA procedures were conducted to
compare means between variable categories as well as parametric and non-parametric multiple
comparisons. Results: Significant differences between the categories of the variables: Eysenck's
personality characteristics, patients' age, occupation, clinical diagnosis and medication were not
observed to either of the two VSSS dimensions used. To the contrary significant results
concerned the differences in the categories of marital status, gender mental health services and
the doctor-patient relationship with "satisfaction with professionals' skills and behavior" and
"Overall Satisfaction". Conclusions: "Overall patient satisfaction", as well as satisfaction with
"Professionals' Skills and Behavior", is not significantly related to diagnosis, ag e, occupation or
personality characteristics. Statistical significance was observed with mental health services and
the doctor-patient relationship. This result supports the viewpoint that patients' judgment is an
appropriate indicator of the provided quality of mental health care. The finding that women and
divorced patients tend to be more satisfied with professionals' skills and behavior may be
attributed to transference and counter-transference.
* The research project is co-funded by the European Union-European Social Fund (ESF) &
National Sources in the framework of the Program "PYTHAGORAS I" of the "Operational
Program for Education and Initial Vocational Training" of the 3rd Community Support
Framework of the Hellenic Ministry of Education.
4.
The Efficacy of Family Adventure Therapy
Yusmarhaini Yusof
Postgraduate Student, University of Bristol
Objective. The research aims to test the hypothesis that addition of adventure therapy to a
standard family therapy (FT + ADT) would increase cohesion between parents and their
62
problematic child compared to those who receive a standard family therapy treatment (FT). The
secondary hypothesis is that family who receive FT + ADT would demonstrate greater
improvement in communication and general functioning than those who only receive standard
treatment (FT). Method. A randomized control trial (RCT) will be utilized to examine the
efficacy of adventure family therapy that deals with the issue of cohesiveness. RCT is a trial
where participants are randomly assigned to either an experimental group which receive the
intervention that is being tested or a comparison group which receive the conventional or
standard treatment (Kendall, 2003). For this study, randomly assigned participants in both,
intervention and control groups will be measured at baseline (pre-test), post-test and during
follow-up. Both groups will receive the standard care which is family therapy and the treatment
group will receive additional care which is the adventure therapy. Discussion. This study has yet
to be conducted by the researcher. However, this poster seeks to discuss the strength/limitation
of the study design.
5.
Provision of Psychiatric Services: A Comparison Between Nrthern Italy and Northern
Norway
Pucci Daniela1, Rossi Alberto1, Amaddeo Francesco1, Rezvy Grigory2, Olstad Reidun2,
Tansella Michele1, Hansen Vidje2
1
University of Verona, Department of Medicine and Public Health, Section of Psychiatry and
Clinical Psychology, Verona, Italy 2University Hospital of Northern Norway, Department of
Clinical Psychiatry, Tromsø, Norway
Objective: To compare two systems of Community Mental Health Care: Verona in Italy and
Northern Norway.Methods: The European Service Mapping Schedule and the Inte rnational
Classification of Mental Health Care were used to describe quantitative and qualitative aspects of
service provision for psychiatric patients, altogether 96 units. Data were collected by face-to-face
interviews with the formal leaders of the units; differences between the two systems were
analysed statistically.Results: Community-based mental health services were well developed in
both regions. In Norway, general practitioners are responsible for primary mental health care,
functioning as gatekeepers to specialised services, in Verona patients can seek care from
specialist services directly. The number of psychiatrists per 100 000 inhabitants was rather
similar (Verona: 15.7, Norway: 13.6; p=0.4). The number of clinical psychologists was 2.4 and
23.1 (p<0.01), respectively; the number of beds was 42.5 vs 91.9 (p<0.01). Day treatment
services for non-acute patients were more developed in Norway than in Verona. Coordination of
care and integration of services were well developed in both regions: in Verona continuity of
care was organised using a single-staff module. Psychosocial interventions were central in both
services: in Northern Norway more emphasis is put on training activities of daily
life.Conclusions: Both service systems were well developed and in accordance with approved
principles in community care, but with surprisingly big differences in number of beds and
number of professionals. Description and comparisons of mental health services across Europe is
possible but requires further refinement.
6.
Evaluating mental health
Pia Solin
Tampere School of Public HealthTampere University EVALUATING
Mental Health Targets Objective: This research aims to describe, analyse and assess the
evaluation process and results of mental health targets. Methods: The research has a grounded
theory based orientation. The empirical data consists of official as well as unofficial evaluations
63
of mental health targets of Health for All –based national health strategies of England and
Finland. Results: It seems that mental health targets are not easy subjects for evaluation. Suicide
presents the only quantitative indicator and is therefore easiest target to monitor. For some of the
targets there was no available monitoring system at all and therefore evaluation of their
advancement was impossible. Conclusions: Evaluators should choose tailored evaluation
methods. Qualitative evaluation methods should not be underestimated, especially with targets
which cannot be evaluated through quantitative methods. There are particular difficulties in
evaluating mental health targets and benefit from them for the future planning of health
promotion policy. For example, many policymakers do not know the terminology, terms or
processes of mental health area and need to have them explained. Furthermore, policymakers
may think that mental health cannot produce proper evidence and therefore the action is useless.
Also decision-makers tend to act on changes and emergencies, which mental health rarely
produces. Finally, policymakers tend to see mental health as a rival to other health issues, instead
of seeing it as part of health. Doing evaluation is not a simple process. Tailored evaluation costs
time, money and manpowe r. Effects of the programme may be difficult to point out as
behaviour is affected by multiple background factors, for example, as is the case in suicide and
mental health problems. Choosing not to evaluate may also be a conscious decision as
stakeholders and policymakers may be afraid of unexpected and unwanted results.
7.
An evaluation of the impact of the move to a new mental health inpatient facility on staff
and patient outcomes”
Aleksandra Urbanska, Fiona Nolan, Stephen Pilling, Sonia Johnson
University College London
Objective: Despite increased interest in the development of community care over the past 30
years, inpatient services continues to receive over 50% of the mental health funding in the UK.
Concerns about the standard of inpatient care have been expressed, particularly over the past
decade. This has led to initiatives to improve services, but there is little evidence as to their
effectiveness. Our aim was to investigate whether the move to a new inpatient premises in
central London was successful in terms of improving staff and patient outcomes. Methods: The
study was conducted between 2004 and 2006, using a ‘before and after’ design. The staff
experience was investigated using the Ward Atmosphere Scale (WAS) and the Maslach Burnout
Inventory. We investigated that of patients using the WAS, the Client Satisfaction Questionnaire
(CSQ) and the ‘Your treatment and Care’ questionnaire. 158 patients were included in the first
stage, and 145 in the second, with response rates of 80% and 75% respectively. Staff figures
were 182 (RR= 80%), and 197 (RR= 74%) respectively. Results: Patient data showed
statistically significant changes in CSQ scores, and in almost all items in the ‘Your Treatment
and Care’ measure. Levels of staff burnout appeared unchanged, expect in rehabilitation wards.
Among the WAS findings were higher levels of staff control as perceived by patients, and lower
levels of anger and aggression.Service level data on untoward incidents demonstrated a
significant improvement following the move. Conclusions: The study sample demonstrated
improved patient satisfaction lower ward incident rates, and similar levels of staff burnout. A
third phase will be conducted in 2008.
8.
Continuity of care as a method of community mental health service evaluation
Małgorzata Pawłowska
Institute of Psychiatry and Neurology, Warsaw, Poland
Objective: Continuity of care is commonly used worldwide, for the evaluation of psychiatric
care, while identified as fundamental quality prevail, important for following psychiatric patients
64
in their environment and life context, for a long time. It is known as a crucial research topic,
enabling the estimation of the quality of community psychiatric services and systems, together
with service planning. The most important intermediate outcome related to continuity of care is
therapeutic relationship. The empirical data show that both continuity and therapeutic
relationship, are associated with treatment outcomes. The project of future studies will be
presented, to recognize the meaning of continuity of care in various forms of outpatient mental
health care for severely ill persons. Methods: Continuity of care will be measured using Service
Need Profile from the Canadian Matryoshka Project, and therapeutic relationship using: Scale to
Assess Therapeutic Relationship (STAR). Service satisfaction together with quality of life (
Lehman Quality of Life Scale) will be assessed. These questionnaires will be translated from
English into Polish and adjusted to polish conditions. Psychiatric health care structure will be
measured by European Service of Mapping Schedule ((ESMS). Socio-demographic data will be
collected and also direct costs using administrative data. Results: It is hoped that the study
results will contribute to the development of community psychiatry in Poland. The closing effect
of research will be the design of new measures for continuity of care and therapeutic
relationship. Creating this tools, which unavailable in Poland, thought recommended by WHO,
is important for the evaluation of new psychiatric care units. Conclusions: It is emphasized to
increase effort to provide continuity of care. This concept might be effectively used to evaluate
community functioning.
9.
Patient and family participation in Belgian mental health care: First results of a pilot study
Else Tambuyzer, Gert Scheerder, Chantal Van Audenhove
Catholic University of Leuven, Belgium
Else Tambuyzer, Gert Scheerder, Chantal Van Audenhove (LUCAS-KULeuven,
Belgium)Financially supported by the Belgian Government .Objective: The present research
aims to investigate the current standings on participation (possibilities) in mental health care
services in Belgium. Participation can take place on three levels: the individual level, the
organizational level, and the policy level. Research on the subject is necessary since participation
of patients and their environment is still in its infancy in Belgian mental health care, particularly
on organizational and policy levels. A pilot study was undertaken to develop an audit instrument
to investigate participation possibilities in mental health care on the three levels in a standardized
way. Methods: A literature study on patient and family participation is conducted and best
practices concerning this topic are identified, in close cooperation with patients, family and their
organizations. Results: The literature study and the identified best practices regarding patient
and family participation will be presented, as well as the audit-instrument.Conclusions:
Continued attention and research concerning patient and family participation is necessary to
enhance the quality of life of people with a mental health disorder and their family.
10.
The Social Location of Need – Surveying Psychiatric Disability in the Community
David Rosenberg
David Rosenberg MSW, PhD candidate, Social Work, Umeå University, Sweden
Objective; The Community Mental Health paradigm has shifted the context for providing
services from the medical/institutional realm to the community, with its array of social and
organisational influences. The aim of this study was to investigate how these changes impact the
manner in which people experiencing serious psychiatric disabilities utilize support
services. Method; Three studies were completed, consisting of seven municipalities in northern
Sweden. A survey was sent to staff of the five primary authorities with responsibility for
addressing the medical, social, financial and employment-related needs of this population.
65
Results of this inventory were then discussed in focus groups consisting of a wide range of actors
in the support system, and analyzed with regard to the community-based needs of these
individuals. Results; As many as 64% of those identified lacked contact with the formal mental
health system, and sought supports related to their lives in the community. These communitybased needs followed patterns related to their ages, vocational interests, family relationships and
wishes for a participatory life, rather than from illness-related factors. Many found themselves in
what staff referred to as “grey zones”, marginalized and without access to relevant supports.
Conclusions; Notions of a target group that present the service system with homogeneous needs
primarily defined by the symptoms of serious mental illness, may be a relic of the
medical/institutional paradigm. The development of a community-based system has allowed for
individuals experiencing psychiatric disabilities to seek supports in a highly individual manner.
Generational factors, organisational barriers and opportunities for participating in community life
all seem to play a role in the development of disability-related needs. Further research related to
social contexts would allow for the planning of more relevant services.
11.
Presentation of the baseline data from the Stockholm follow-up study of users diagnosed
with psychosis”
Alain Topor
Sweden
Objective: To describe the first preliminary results from a Swedish longitudinal, naturalistic
and prospective cohort study of users diagnosed with psychosis (including schizophrenia). The
study’s aims are:





To study the illness and recovery process
To examine the interventions of psychiatry, general healthcare and the social services and
the correctional treatment of offenders
To study the efforts of the users themselves and of their social networks
To study users’ evaluation of these efforts and interventions
To develop hypotheses about the relationships between efforts/interventions and
outcome.
Method: During a period of 5 years 1,501 users are being followed up using data from registers
covering psychiatry, socio-demography, somatic health, social services, crime and correctional
treatment of offenders. Additionally, a sub-sample of 108 individuals are also being followed up
through records and instruments for assessing symptoms, level of functioning, medication, sideeffects of medication, quality of life, therapeutic alliance, recovery factors and interpersonal
relationships. Furthermore, 20 of the users were strategically selected and are being interviewed
every fourth month during a three-year period. Results: Data will be presented concerning the
use of health and social care, and the rates of compulsory treatment and criminality.
Conclusions: The preliminary findings highlight the importance of collecting data from diverse
sources that reflect the various environments where users now live after the
deinstitutionalization. A broader focus than on psychiatry alone makes it possible to obtain a
more comprehensive picture of the living conditions of the users and of the interventions and
efforts of different caregivers.Per Bulow: Phd Anne Denhov: MSScSara Holmqvist: MSScGuy
Karlsson: RNMaria Mattsson: PhdAlain Topor: Associated professor Psychiatry South
Stockholm, Research and Development Unit and Stockholm University, Department of Social
Work
12.
Characteristics of residential resources for adults with severe mental illness: Modeling &
comparison of classification
66
Amélie Felx OT1, PhD student 2,3, Alain Lesage2,3, MD, MPhil, Marc Corbière4, PhD
1
Douglas Hospital, Residential Resources Department 2Department of Psychiatry, Université de
Montréal 3Fernand Séguin Research Centre 4CAPRIT, Université de Sherbrooke, Canada
A variety of residential resources have been developed in order to provide housing along with
the support required to enable adults with severe mental illness to lead satisfying lives in the
community. In Quebec, Canada, approximately 6853 adults with severe mental illness live in
residential resources recognised by the government. As we try to understand residential
resources a misunderstood heterogeneity and functioning are unveil. Reliable information to
guide resources allocation and housing improvement is still scarce. Objective: The objective of
this presentation is twofold: 1) to introduce the methodology (mixed methods) of a research
project to be conducted in Quebec and investigating the structural and process characteristics of
a spectrum of residential resources; 2) to present a preliminary model that synthesizes key
components of residential resources. Methods: Because of the complex nature of residential
resources and existing evidences, the research project focuses on preliminary phases (theory and
modelling) of the evaluation of a complex intervention. The project overall aim is to explore
different classifications of residential resources for adults with severe mental illness using the
assumption that both structural and process characteristics should be considered
comprehensively. A preliminary modelling exercise was performed based on a literature review
and the Mental Health Matrix. Therefore, the model divides residential resources in a temporal
(input, process, outcome) and a geographical dimensions. Conclusion: Better understanding the
characteristics and the functioning of residential resources is crucial to identify its active
ingredients. The results of the research project could guide the development of residential
programs of quality which promote the recovery of adults with severe mental illness.
13.
Duration of untreated psychosis and level of expressed emotions as predictors of relapses in
the long-term outcome of schizophrenia.
Andrzej Cechnicki, Igor Hanuszkiewicz, Romuald Polczyk
Community Psychiatry Unit, Chair of Psychiatry, Institute of Psychology, Jagiellonian
University, Cracovian Schizophrenia Research Group
Objective: The Cracow Study on the Course of Schizophrenia is a prospective, real-time study.
The duration of untreated psychosis (DUP) as well as the level of expressed emotions (EE) in the
family are described as important predictors for the course of schizophrenia. The presented study
investigates the way in which EE and DUP correlate with long term outcomes of the treatment
and the course of illness. Subjects and Method: 58 DSM III schizophrenia diagnose patients
(i.e. 72,5 % of the preliminary group n=80) took part in 1, 3, 7 and 12 follow-up. Their average
age was 27,3 at the time of the first episode. The Follow-Up Chart, BPRS, and Camberwell
Family Interview (CFI) were used. In the presented study only the number of relapses was
included as the outcome criteria. ANOVA with two between-subjects factor (DUP and EE) and
one repeated measures factor (the number of relapses) was calculated to determine whether the
increase of the number of relapses is related to DUP and EE. The significance of all possible
interactions, as well as main and simple effects was calculated. Results: 1/The number of
relapses increased significantly over time (F3,162 = 35.06, p < .001). 2/The increase of the
number of relapses was more pronounced in the group with a long DUP (F3,162 = 2.87, p =
.038) 3/ The increase of the number of relapses was more pronounced in the group with a high
EE (F3,162 = 3.03, p = .031) 4/ The impact of DUP on the number of relapses was not
moderated by EE (F3,162 = 0.63, p = .599) Conclusion: 1/ Both DUP and EE modify the
dynamics of relapses during 12 years of illness. 2/ A short DUP has a positive influence on the
number of relapses in long-term but not in short-term outcomes 3/ A low EE has a positive
67
influence on the number of relapses during all 12 years of illness 4/ DUP and EE do not interact
in their impact on the number of relapses. A short DUP does not protect from a high EE and a
low EE does not protect from a long DUP.
14.
Dynamics of positive and negative syndrome and their predictors in 12-year schizophrenia
prospective study
Andrzej Cechnicki
Community Psychiatry Unit, Chair of Psychiatry, Jagiellonian University, Cracovian
Schizophrenia Research Group
Objective: The aim of the study was to examine the course of schizophrenia, especially the
dynamics of the positive and negative syndrome and to identify the predictors that influence the
course of the illness. Subjects & Method: The data concerning 22 predictors was gathered from
80 patients suffering from DSM-III schizophrenia at their first hospitalisation. They were
followed up in 1 year (n=76), 3 years (n=74), 7 years (n=71) and 12 years (n=72). The average
age at the 12th year follow-up was 39,2 years, 58% of the subjects (n=42) were female and 42%
(n=30) were male. Among others Predictors’ Chart and Catamnestic Chart, BPRS-LA, GAS,
Strauss-Carpenter Outcome Scale were used. The influence of predictors was assessed by the
stepwise regression analysis. Results: After the first hospitalisation the positive syndrome
decreases fast and the negative syndrome decreases slowly. Over the course of 12 years the mean
level of positive symptoms remains stable and negative symptoms show mild increase. The
highest “general severity of symptoms in last month” gauged with Strauss-Carpenter Outcome
Scale is in 48% explain by a greater number of negative symptoms at the time of the first
hospitalisation and a lower education. Similarly, these two predictors explain in 50% general
severity of symptoms assessed with BPRS-LA. The severity of positive symptoms is in 50%
explain by the constellation of: the severity of positive symptoms after the first hospitalization,
the lack of social contacts outside the family, a low education level, participation in an individual
treatment program, as opposed to a community program, during first years of the illness. A
higher severity of negative symptoms assessed with BPRS-N is in 29% explain by a higher
severity of negative symptoms assessed with BPRS-N after the first hospitalisation and a lower
education before the onset of the illness. Conclusions: 1/ The positive syndrome decrease after
the first hospitalisation and becomes stable, whereas the negative syndrome decrease slowly in
the first year and then becomes slightly increasing. 2/. The positive syndrome is explained by a
broader spectrum of social prognostic factors. 3/ The severity of negative symptoms in 12 years
follow-up is explained by the severity of the negative symptoms which remain after the first
hospitalisation.
15.
Results of rehabilitation of persons suffering from chronic schizophrenia.
Aneta Kalisz, Andrzej Cechnicki, Igor Hanuszkiewicz
Community Psychiatry Unit, Chair of Psychiatry, Jagiellonian University, Cracovian
Schizophrenia Research Group
Objective: Evaluation of the efficacy of a complex rehabilitation program in a group of persons
suffering from chronic schizophrenia. Subjects: 47 persons (22 F and 25 M; the average age was
33 years) diagnosed with schizophrenia (ICD 10) and at least 3 months of participation in the
rehabilitation program were included in the study. The majority of the subjects were of single
status (88%), with primary or secondary education (87%), still living with their parents (73%).
All subjects had lost their jobs and were on pension. Method: The evaluation was conducted at
two points: at the time of inclusion in the study and after five years of participation in the
rehabilitation program. Both the choice of drugs and the rehabilitation program was considered
68
individually and according to clinical indications. The data collected included:
psychopathological symptoms assessed with PANNS, information concerning the number and
time of re-hospitalizations, clinical assessments of social contacts, living situation and
professional occupation. The quality of life was assessed with the Lancashire Quality of Life
Profile. To compare the results T-test and Wilcoxon’s test were used. Results: During five years
of participation in the intensive rehabilitation program the level of positive symptoms becomes
stable, whereas the level of negative symptoms continues to increase. The number of rehospitalizations drops evidently. The network of social contacts grows, going outside the walls
of institutions. The ability to take up a job does not change. The subjective quality of life does
not change either. Conclusions: The most significant effect of including patients suffering from
chronic schizophrenia in an intensive rehabilitation program is a decrease of the number of rehospitalizations, an extension of the time spent outside hospital and a development of social
contacts.
16.
Relation between long-term dynamics of social network, type of therapeutic intervention
and indicator of emotion expression in families of persons suffering from schizophrenia
Anna Wojciechowska, Andrzej Cechnicki
Community Psychiatry Unit, Chair of Psychiatry, Jagiellonian University, Cracovian
Schizophrenia Research Group
Aim: The aim of the study was to assess the relation between the dynamics of changes in social
network throughout 12 years of illness, participation in either "individual" or "community"
program of treatment (ITP vs. CPT), and the level of expressed emotion in family (EE) at the
time of first hospitalization. Subjects and Methods: 54 DSM-III schizophrenia patients (70%
of the initial group, n=80) participated in the study.The EE was assessed with CFI, social
network dynamics at the 3, 7 and 12 year follow-ups were assessed with Bizon's questionnaire.
Intra-group and inter-group comparisons of social network variables and their relation to the
level of EE were assessed using ANOVA. Results: The range of social network changes over 3,
7 and 12 years with many contacts lasting over 10 years. Only at the 7-year follow-up did the
subjects participating in the ITP have more favorable relationships in and outside family, as
well as a more favorable mixed type of support system in and outside family, as compared to
the CTP participants. Among the persons with a low EE an increase in the favorable mixed type
of support system is observed, and it becomes significant at the time of the 12-year follow-up.
The persons with a low EE have a smaller network range and a lower level of social support.
There was not found any significant relation between network dynamics, the type of treatment
program and the EE observed at the times of the follow-ups. Conclusions:1/ In a short–term
course of schizophrenia the dynamics of social networks vary between ITP and CTP
participants, although in long term the difference vanishes. 2/ A low level of expressed emotions
corresponds with an increase of the favorable mixed type of support system over the first twelve
years of illness.
17.
Public attitudes towards people with mental illness in England and Scotland, 1994-2003
Nisha Mehta1, Aliya Kassam2, Morven Leese2, Georgia Butler2 and Graham Thornicroft2
1
King’s College London School of Medicine, 2Section of Community Mental Heath, Health
Service and Population Health Research Institute of PsychiatryKing’s College London
Objective: Knowing trends in public attitudes towards people with mental illness informs the
assessment of ongoing severity of stigma, and evaluation of anti-stigma campaigns. The authors
69
analyse trends in public attitudes towards people with mental illness in England and Scotland,
using Department of Health Attitudes to Mental Illness Surveys, 1994-2003. Method: We
analysed trends in attitudes for 2000 respondents (6000 respondents in 1996 and 1997) using a
quota sampling methods and an adapted Community Attitudes towards Mental Illness Scale
consisting of 25 items. Results: We compared attitudes at various time points between 1994 and
2003 loo king for significant changes within items and looking for differences between England
and Scotland. Conclusions: Analysis of public attitudes towards people with mental illness in
England and Scotland 1994-2003 yielded interesting results. Analysis of the trends can help
inform the evaluation of anti-stigma campaigns.
18.
General population knowledge and attitudes regarding depression and suicide in Belgium
Gert Scheerder1, Alexandre Reynders2 & Chantal Van Audenhove1
1
LUCAS, Catholic University of Leuven, Belgium2 Center for the Prevention of Suicide,
Belgium
Objective: Knowledge and attitudes regarding mental illness strongly impact upon whether and
how professional help is sought by people affected and are important to understand
stigmatization. Several studies indicate a lack of knowledge and rather negative attitudes to be
present among the general population, especially in comparison to physical diseases. In Belgium
almost no data are available on this issue. We therefore undertook a pilot study, specifically on
depression and suicide. Methods: Semi-structured interviews (n=60) with members of the adult
general population were held on the following topics: perceived symptoms and causes of
depression and suicide ideation, preferred treatment and perceived effectiveness, reactions to
people affected, and knowledge of mental health services. Results: Knowledge of depression
symptoms was good, but knowledge of mental health services moderate. Attitudes towards
suicide appeared to be rather negative and confirmed common myths on suicide. Life events
were the predominant explanation for causes of depression, in contrast to biochemical or
hereditary factors. Consequently, negative attitudes towards antidepressants prevailed. Almost
half of respondents indicated that they would try and solve depression themselves. Professional
help would be sought only in severe cases. Comparison of open-ended and closed questions
revealed that closed questions more frequently lead to socially desirable answers. Furthermore,
there was a notable difference between treatment options people would advice to relatives, in
comparison to what they would do themselves. Finally, people’s experience with depression or
suicide in their personal environment appeared to serve as their framework.Conclusions: These
baseline data provide very useful information to set up evidence based action to increase mental
health literacy and to fight stigma.
19.
Does illness duration matter for stigma perception?
M. Freidl1, Seyringer M. 1, Wancata J. 1, Strobl R. 1, Weiss M. 1, M. Scherer 2, Katschnig
H. 2,1
1
Department of Psychiatry and Psychotherapy, Medical University of Vienna; 2Ludwig
Boltzmann Institute, Department of Social Psychiatry Vienna
Objectives: It is well known that the general public has negative attitudes towards persons
suffering from mental disorders and that patients do perceive these attitudes and may be
influenced in their service use by these opinions. An open question is whether patients’ stigma perception increases or decreases over time. The present study investigates this question.
Methods: 99 patients who suffered from schizophrenia were included in the study. The average
illness duration was 12.2 years, the mean duration of treatment was 10.2 years. The « Stigma70
questionnaire » by Link et al (1987, 1989), which asks patients what they think that most people
think about psychiatric patients was given to these patients. Results: The mean age of the
patients was 34 years. Sixty-one percent of the patients were male. Only 6% were living together
with family or a partner. The analysis showed that stigma perception starts on a rather high level
and increases over many years of illness, but finally flattens off and even
decreases. Conclusion: Stigma perception changes over time and this has to be considered
when services are offered to psychiatric patients.
20.
Pathways to successful living in the community after institutional care
Knud Ramian, Birgitte Ahlgreen
Centre for Quality Improvement, Aarhus, Denmark
Objective: The study is part of a national study of the impact of the social policy on vulnerable
young people. The objective of this study was to identify the pathways which lead to successful
social integration for younger people with schizophrenia. Methods: The study is a multiple case
study of successful integration. Criteria for inclusion were stable independent housing, work or
educational activities and no abuse of drugs two to five years after relocation. Six men and three
women with schizophrenia, age 26-37 were identified. After extended periods in mental
hospitals they lived in various institutional care settings for 3-5 years. The ex-residents and
professional staff were interviewed to identify progress on various measures of social
integration. Results: The rehabilitation models in the institutions varied, but all cases
experienced positive personal outcomes during their stay due to a very individualized
rehabilitation process. A will to recover became prominent during the stay and their readiness for
relocation was independent of staff evaluation. Financial security (social pension) and job or
educational activities were established during the institutional stay and could be sustained. The
transition to the community seems critical and this process was very dependent on the
institution’s ability to provide care after the relocation. Even residents with lifelong continuing
psychopathology were capable of independent living if an acceptable support system could be
provided. Conclusions: A long individualized rehabilitation process led to a preferred
independent living even in the face of considerable continuing psychopathology. The institutions
played a crucial role after the transition from institution to community. More than personal
development and recovery the institutions especially adde d basic elements to the future living
situation which sustained after the relocation.
21.
Acute Wards and Residential Alternatives: A Comparison of the Care Provided
Brynmor Lloyd – Evans1, S.Johnson1, D.Osborn1, H.Gilburt2, M.Slade2
1
Dept. Mental Health Sciences, University College London, UK
2
: Health Services and Population Research Dept, Institute of Psychiatry, UK
Background: Acute psychiatric inpatient wards have been the focus of widespread
dissatisfaction. The Alternatives Study is an NHS-funded, UK national study evaluating
residential alternatives to standard acute wards. The study has involved assessing the content of
care at alternatives and standard services. Method: Three measures were developed and used at
four alternative and four standard inpatient services.1) CaSPAR: a measure of the amount of
staff-patient contact at services using researcher observations (n = 224).2) CaRICE: a measure of
the types of care provided at services: a staff-completed one-week record of all contacts with
service users 3) CCCQ(P): a service user-completed questionnaire measuring the types and
amount of care received during an admission (n = 320). Results: 1) A descriptive comparison of
the care provided at alternative and standard inpatient services will be reported.2) Analysis of
71
associations between content of care provided and patient outcomes will be presented.
Conclusion: How and to what extent residential alternatives differ from standard inpatient
services will be discussed. Implications about what constitutes effective inpatient care will be
considered.
22.
Creating the network of community services for mentally ill in cooperation of psychiatry
professionals, NGO and social help workers
Maria Załuska, Dorota Suchecka, Anna Kossowska, Michał Kuroń, Bertrand Janota
IV Department of Psychiatry of the Institute of Psychiatry and Neurology in Bielański Hospital in
Warsaw.
Objective The psychiatry departments in the general hospitals were perceived as the key
institutions in the psychiatry reform in Poland However after the implementation of Mental
Health Act in 1994 , the close cooperation between health professionals, social help workers ,
patients , families and NGOs is the best start point for developing the efficient community
network of psychiatric services. Methods: The efforts to create complexity and continuity of
psychiatry community care in the Warsaw Districts Bielany and Zolibórz were analyzed. The
unmet patients needs were taken into special consideration. Results : Since 1970 outpatient
clinic and psychiatric day ward were functioning in that part of Warsaw. After the 1995 two
Community Day Centers of Mutual Help (CDCMH) for mentally ill Persons were introduced in
the social help system , and Specialized Psychiatric Services at Client Homes were realized with
the participation of NGO POMOST. Since 2002 psychiatric ward with 30 beds, psychiatric
emergency and out-patient clinic has been implemented in the Bielanski Hospital. After there
the day ward was reorganized in order to shorten the duration of stay and deliver more active
treatment instead of supportive role undertaken by CDCMH. Supportive and therapeutic groups
for young people with psychosis and their families were introduced. At the same time because
of the refusal of NFZ to finance the rehabilitation camps , the new NGO : Association for
Supporting Community Psychiatry (Prof. Andrzej Piotrowski Association ) was creating , and
organizing two camps with financial support of PFRON and Social Help. Conclusions : The
close cooperation between mental health units social help services and NGO is necessary for
developing psychiatric community care system and reacting adequately for the patients unmet
needs. The current urgent needs are to create Community Mobile Team , and introduce
programs of supportive employment for mentally ill. The needs of mentally ill adolescents and
young people are poor recognized.
23.
Systematic and overall implementation of Skills Training Modules for people with
schizophrenia”
Nicole van Erp1, M. van Vugt1, D. Verhoeven2, H. Kroon1
1
Trimbos Institute, 2Dutch Liberman Foundation, Denmark
This presentation focuses on the results of an implementation project carried out in three Dutch
mental health institutions. Aim of the project was to enhance systematic and overall
implementation of the Medication and Symptom management modules in three mental health
institutions. Methods. The participating mental health institutions are located in three different
regions: Veluwe/Flevoland, Brabant and Twente. Main selection criteria were a consistent
though limited implementation of the modules, and willingness and enthusiasm to develop a
broad, continuous provision of the modules. The participating institutions are large regional
facilities with bo th hospital and outpatient settings. Data of the implementation study were
collected from May 2005 to December 2007. The reach of the implementation was assessed at
30 months. Information on barriers and facilitators for implementation and on integration into
72
usual care was gathered at 0, 12 and 24 months through semi-structured interviews with
managers, program leaders, trainers, care providers and clients. Results. Overall implementation
of the skills training modules for 74% of the entire target group was not feasible at the three
agencies. Implementations were impeded by an unmotivated program leader, organizational
changes, disappointing referral of clients, loss of (supervisor) trainers and logistic problems.
However, the mental health agencies made important steps forward to integrate the modules into
usual care. All institutions incorporated the modules into their policy plans and ensured continual
education of new trainers and supervisor trainers in their organization. Two out of three
institutions also incorporated the modules into their care programs for schizophrenia and related
disorders, made the modules a regular item in team meetings, arranged central coordination of
training sessions for clients, and made long term financial arrangements.
24.
Costs and cost-effectiveness of the individual placement and support (ips) model of
supported employment: A review of the literature
Eric Latimer
Ph.D., McGill University (Canada); Personal Social Services Research Unit (UK)
Objective: To review the literature pertaining to the costs and cost-effectiveness of the
individual placement and support (IPS) model of supported employment for people with severe
mental illness. Methods: A systematic review of the literature until December 2007 was
conducted. Results: Eleven randomized controlled trials (RCTs) of IPS and four of pre-IPS
services, 9 pre-post or quasi-experimental studies, and two long-term follow-up studies were
identified. All studies find that IPS increases competitive employment. Only the two long-term
follow-up studies provide (weak) evidence of benefits in terms of non-vocational outcomes such
as self-esteem. The costs of vocational services that IPS may displace m ay either exceed, or be
smaller than, those of IPS. Among 4 RCTs, only the European EQOLISE trial shows reduced
hospital use for IPS participants. Among 5 quasi-experimental studies, 2 provide evidence of a
reduction in hospitalizations. One RCT finds no evidence that IPS affects use of outpatient
services, while 2/5 quasi-experimental studies find evidence of a reduction. Five out of 6 studies
show lower overall costs for IPS, but the differences are either non-significant or not tested. As
additional earnings from IPS tend to be small (about $500 to $1,500 per person per year) impacts
on welfare payments and tax revenues are small. Further studies suggest that cost-effectiveness
is likely to be highest for high-fidelity programs operating in settings where unemployment rates
are lower and where incentives encourage working longer hours. Conclusions: There is growing
evidence of some health care cost offset, for which the literature suggests plausible causal
mechanisms. Long-term cost-effectiveness may be greater than suggested by shorter-term
studies.
25.
Barriers to employment of mentally ill persons
Janusz Morasiewicz, Łukasz Cichocki, Igor Hanuszkiewicz
Community Psychiatry Unit, Chair of Psychiatry, Jagiellonian University, Cracovian
Schizophrenia Research Group
Objective: 1)Identification of barriers to empolyment and work from the perspective of mentally
ill persons. 2)Description of factors that influence this perspective. Method: A list of 21 possible
barriers, which had been constructed during interviews with mentally ill persons, was presented
to a group of 81 subjects. They were asked to choose 15 most important barriers and arrange
them in order from the most to the least important. The mean age of the subjects was 35 years.
The group consisted of 42 women and 39 men. The mean time of rehabilitation was 4 years, the
73
mean number of hospitalizations equalled 3,84. The mean duration of education was 13 years,
the mean work experience was 5,38 years. Results: The most important barrier was: “employers’
mistrust in effective work performance of mentally ill persons”, followed by “the risk of
relapse” and „the fear of showing symptoms of mental disorder”. Generally, the most important
barriers were of a subjective and psychological character. Objective and social barriers were
indicated as less important. The effect of the education level on perception of the barriers was
eminent. The higher the education level, the more important the barriers connected with social
anxiety were. The longer the duration of rehabilitation, the less important the barrier „employers’
mistrust in effective work of mentally ill persons” was. The longer the work experience, the less
important the barriers: „lack of motivation among mentally ill toward changing their life
situation”, „lower self-esteem of mentally ill” and “the families’ mistrust in effective work of
mentally ill persons” were. Psychopathological status – a higher level of negative symptoms
influenced perceiving of the barriers „lower self-esteem of mentally ill” and „the fear of
mentally ill people” as more important. Family influence and pharmacotherapy (typical/atypical
neuroleptics) were not found to be statistically significant factors. Conclusions: Opinions of
mentally ill persons concerning their barriers to employment and work constitute an important
factor to be considered in planning of treatment and rehabilitation programs.
26.
Study of the Pan Cogito Hotel Social Firm Culture
Ptyushkin P1., Cichocki Ł2
1
Europubhealth Master Program, Institute of Public Health, Jagiellonian University
2
Community Psychiatry Unit, Chair of Psychiatry Jagiellonian University, Cracovian
Schizophrenia Research Group
Background: The important goal is to promote and support special projects of employment for
people with mental health problems, which are created by non-government organizations. The
undertaken research is led in the Cracovian rehabilitation institutions of the Association for
Development of Community Psychiatry and Care, and since 2006 focused on the identification
of restrictions and possibilities concerning employment of people with SMI. The aim of the
present study was description of “U Pana Cogito Hotel”- Social Firm Culture by using the mix
of quantitative and qualitative methodology. Subjects and Method: study group: 21 workers(16
F, 5 M) with serious mental illness. Distribution by age: between 23 and 40 years old- 11
persons, above 41 years old- 10 persons. The duration of illness is from 4 years to
25.Quantitative part consisted of 4 questionnaires: External evaluation of worker by manager of
the hotel, Auto evaluation by worker, Social Inclusion Questionnaire and SF-12 questionnaire
describing quality of life. Qualitative part is represented by the analysis of the guest-book
comments from the moment of the opening of the hotel till the present day. Also 300 Individual
Guest Questionnaires was analyzed. All comments, related to the culture of the hotel (according
to the proposed definition) were selected. Similar comments were grouped together and
submitted to the frequency analysis. Results: The results of External and Auto evaluation of
work quality are similar what shows that workers perceive themselves realistically, are aware of
their strong and weak sides and are able to work at their current workplace as good as healthy
staff. The results of SF-12 revealed two groups – a major one with high medium MCS and PCS
scores and a second one with high PCS but very low MCS. Grade of social inclusion perceived
by workers revealed a high grade of satisfaction of workers with their housing, contacts with the
health care sector and legal sector (police, etc.). At the same time they perceive that their social
life does not depend on mental health services and most of them feel themselves in some grade
part of the local community. However the access to work and education is perceived as poor and
almost half of workers felt discriminated once or twice when trying to get an employment. It can
be seen from the comments, the majority of them concern professional qualification of workers
that is very positively evaluated. Other comments underline the nice/friendly/pleasant
74
atmosphere of the Hotel, created in great part by workers. Conclusions Results of the study
provide additional information about the mentally ill workers of a social firm. They show that
workers perceive themselves realistically, adaptable to the environmental requirements. They
also feel themselves in some grade socially included and for the majority of them the selfperceived quality of life is close to the general population level. The information provided by the
external sources (manager of the hotel, guests) assure that such social firm workers have good
professional and personal skills to create a pleasant atmosphere at the hotel and are perfectly
suitable for such kind of work.
27.
How much does it cost to obtain employment, and is it a good investment?
Justine Schneider and colleagues
University of Nottingham and Nottinghamshire Healthcare Trust
Objectives: We studied the costs of obtaining work and whether entering employment made a
difference to service users’ consumption of other services. Methods: The SESAMI (Social
Inclusion through Employment Support for Adults with Mental Illness) study was a naturalistic
investigation of people with severe mental health problems receiving supported employment
2003-2005, funded by the European Social Fund. It followed up 155 individuals over one year,
measuring the services they used, together with the social security benefits and income received.
In this analysis we look at the study cohort as a whole, and also compare groups of individuals
at different stages on the employment pathway. Results: For every client who was placed in
work during the study, three were unsuccessful. A handful of people in work at the outset (5/48)
lost or gave up their jobs. There were minor reductions in the rate of use of some services but
none of the changes in aggregate costs was significant. We infer that supported employment per
se did not affect costs of health and social care. People who moved into work showed a
significant reduction in their use of mental health services. People who remained unemployed
incurred higher social services costs and use of (non-psychiatric) hospital care increased. When
we looked separately at the costs and income of people at different stages of employment, a clear
gradient emerged, with shrinking costs to the state sector and rising personal incomes the longer
people worked. Conclusion: Employment for people with mental health problems is associated
with shrinking public sector costs and increased earnings. This effect may be masked by a
failure to distinguish between people at different stages on the road to employment.
28.
Oral health and relation to quality of life in individuals attending Swedish out-patient
psychiatric care
Karin Persson1, Björn Axtelius2, Björn Söderfeldt2, Margareta Östman1
1
Faculty of Health and Society, 2Faculty of Odontology, Department of Oral Public Health
Malmö University Sweden
Objective: Oral health has improved among parts of the Swedish population during the past
thirty years. Investigations about living conditions indicated that Swedish people with mental
health problems don’t follow that pattern. In the change to out-patient care oral health has
become an individual matter with limited possibilities to enhanced interest from both psychiatric
services as well as the dental health care systems. Few investigations have explored oral health
in out-patient care and none of them has focused how oral health is related to the perception of
quality of life. Method: This investigation focuses both an objective assessment of oral health
and assesses, by the way of a structured interview, how oral health affects quality of life in a
heterogeneous population in out-patient psychiatric care. Included in the investigation were 113
patients. Results: The results showed that numbers of missing teeth were related to diagnosis,
75
age, oral hygiene and neuroleptic drugs. As to mucosal status mucosal inflammation was related
to diagnosis and gender. Need for dental treatment was found in more than two thirds. Dental
attendance was found similar to a Swedish population and not related to dental fear. Oral health
impact profile (OHIP-14) was found associated with subjective quality of life (Mansa) and health
related quality (SF-12). Correlation was also found to ratings of self-esteem (Rses), sense of
coherence (SOC) and the chance-subscale in Multi-Health-Locus of Control scales. The findings
were found to differ significantly from the general Swedish population. Conclusion: Decreased
Oral health related quality of life (OHRQoL) seems to be associated with the perception of oral
problems.
29.
Physical health- a cluster randomised controlled life style intervention among persons with
a psychiatric disability and their staff
Karl-Anton Forsberg, Tommy Björkman, per Olof Sandman, Mikael Sandlund
KARL ANTON FORSBERG; R.N., MSc, Phd stud, Dep. of Nursing, Umeå University, Umeå,
Sweden and The Vårdal Institute, Lund, Sweden.TOMMY BJÖRKMAN; R.N. , PhD., Ass
professor, Dep. of Health, Lunds University. Sweden. PER OLOF SANDMAN; R.N. , DMSci.,
Professor, Dep. of Nursing, Umeå University. Umeå, Sweden.MIKAEL SANDLUND; M.D.,
PhD. Ass professor, Dep. of Clinical Science/psychiatry, Umeå University, Sweden.
Objectives. The objective was to explore the impact on physical health of a life style programme
among persons with psychiatric disabilities, and their care givers. Their satisfaction with the
intervention was also assessed. Methods. Forty one persons with a DSM- V diagnosis of
severe mental illness from psychiatric disability from ten supported housing facilities and 41 of
their care givers participated in this 12 month study during 2005- 2006 in Sweden. The
supported housing facilities with residents and staff were randomly assigned to either a health
intervention programme or a control programme with an aesthetic content. The presence of
Metabolic Syndrome and changes in the mean of physiological parameters such as Hba1c, Pglucose, P- insulin, lipids, blood pressure, physical working capacity, BMI, HeartScore were
investigated and participants’ satisfaction assessed. Results. There was a significant reduction in
the mean of metabol ic syndrome criteria in the intervention group compared to control group at
the follow-up. The participants expressed satisfaction with the program. Conclusions. The
results indicate that health interventions on life style issues when involving carers are
appreciated, feasible and could be successful in reducing some health related risk factors among
persons with psychiatric disabilities.
30.
The Outcomes of Custody Diversion For Mentally Disordered Offenders: A Realistic
Evaluation
John Carpenter1, Wendy Dyer2
1
University of Bristol - UK, 2 University of Northumbria - UK
Objectives: To examine the process and outcomes of the work of a custody diversion and liaison
team (CDLT) for mentally disordered offenders (MDOs), in particular the ouutcomes for those
who charged with crimes of violence. CDLTs in England provide support to MDOs and advice
to social services, probation and the courts. Outcomes were subsequent offending and psychiatric
hospitalisation. Methods: An observational study based on a realistic evaluation methodology
(Pawson and Tilley, 1997). The authors constructed and analysed datasets linking the pre- and
post- discharge psychiatric histories and criminal records of MDOs referred to the CDLT with
the team’s actions. The sample comprised all MDOs (N = 4093) referred between 1995 and
2004. Results: Logistic regression analysis revealed that by far the strongest statistical predictor
76
of re-offending was previous convictions. Similarly, psychiatric hospitalisation was predicted
most strongly by previous psychiatric history. Violent offenders assessed by the team were
significantly less likely to be reconvicted in the following 3-12 months than non-violent
offenders (29% vs. 39%). Cluster analysis revealed four distinct career types with very different
outcomes. Over half of those with significant previous offences re-offended, whether or not they
were assessed. The team was more successful with MDOs with a psychiatric history and less
serious offences; only 19% of those who were assessed and received mental health care
subsequently re-offended. A third of those referred had no criminal or psychiatric history; most
of these were assessed and received advice, and fewer than one in ten went on to
offend.Conclusions: While it is clear that custody diversion and liaison did not work equally
well for all groups, there is evidence to support its place within a comprehensive service system.
31.
Experiences of alcohol and other drugs in individuals with psychotic disorder and
a concomitant substance use disorder
Gunilla Cruce1, Agneta Öjehagen1, Monica Nordström2
1
Department of Clinical Sciences – psychiatry, Lund University Hospital, Kioskg. Lund,
Sweden, 2Department of Social Work, Göteborg University, Sweden.
Objective: It is well known that comorbidity between substance use disorders and psychotic
disorders is common. Owing to the distressing social, psychological, psychiatric and somatic
consequences of this comorbidity it is of vital importance to deepen the understanding about the
individuals’ own experiences of their alcohol and drug use. Methods: Eight individuals were
interviewed twice. The interviews, which were based on an interview guide, were transcribed
verbatim and analysed thematically. Results: Alcohol and drug use influenced the individuals’
own experiences of their health and life situation both in a positive and negative way. The
substance use had significance for their 1)self-experiences – i.e. wellbeing and discomfort, energy
and powerlessness, meaning and disorientation, identity and change of personality; 2)experiences
of the psychotic disorder – i.e. decreased and increased symptoms; 3)experiences of relations –
i.e. affiliation and alienation. Conclusions: It seems important when providing treatment and
support to be aware of individuals’ own motives for using alcohol and drugs. From the
individuals& rsquo; point of view their misuse appeared as a reasonable, but misguided effort to
obtain control over their health and life situation.
32.
Evidence- based clinical management of schizophrenia: Focus on active monitoring, shared
decision – making and optimal pharmacotherapy
Eva Lindström, Swedish Care & Treatment of Psychoses Committee
Department of Forensic Psychiatry, Malmö, Lund University, Sweden
Background: For 150 years schizophrenia patients received comprehensive and life-long care in
institutions. Chlorpromazine brought hope for cure 50 years ago. However in the 1960s
treatment algorithms were affected by the political environment and influenced by the
antipsychiatric movement. Today focus has shifted to disease management and monitoring on an
individual level, in order to maximize quality of life. Objective: To introduce new perspectives
on the long-term outcomes in mental health practice with the intention of improving adherence
and outcome. To explore the role of the following elements in an integrated s ervice strategy:
optimal antipsychotic dose, active monitoring and clinical management, shared decision-making,
and improving cognitive aptitudes. Methods & Results: There should be regular monitoring
(both pre-treatment and during treatment) of core physical health indices. These include
cardiovascular parameters (ECG, particularly the QT interval which is affected by many
antipsychotics), blood pressure, glucose and lipid profile, weight, dental health and neurological
77
symptoms (because such side effects are common and amenable to treatment). Monitoring these
and other indices related to, for instance, symptoms, general well-being and life-style will allow
proactive rather than reactive actions to be taken. Inviting patients to participate on equal terms
with respect to monitoring will improve motivation, self-care skills and compliance, and thereby
also the overall outcome of community based treatment programs. Besides minimising sedation,
monitoring should also address cognition – the most important factor for long-term outcome.
Even limited effects achieved by optimizing drug treatment and training failing functions can
improve outcome significantly. Conclusions: Patients appreciate being carefully monitored and
involved in decision-making for their illness and it contributes positively to outcome.
33.
Bridging the gap between mental health and social services for the benefit of patients with
dual diagnoses
Sophia Eberhard, Erici C, Haldeborg J, Cruce, G
Eberhard S, Erici C, Haldeborg J and Cruce, G Lund University Hospital, Kioskgatan Lund,
Sweden
Background: Accessibility to treatment for persons with dual disorders (mental illness and
substance use disorders) is restricted, in part depending on barriers between organisations. Due
to the lack of coordinated examination and treatment these persons frequently receive no or
insufficient treatment, resulting in a deterioration of health, and life situation. Method: In the
city of Lund with surrounding municipalities in Skåne County in southern Sweden we
established a one year trial multi-professional team with mental health, social services and
primary care staff to examine possible comorbidity between mental illness and substance use
disorder. Examination results, including diagnoses and psychosocial needs, were presented in a
"systemic meeting" in the presence of the client, as well as professionals belonging to the current
and future treatment network. The "systemic meeting" method promotes people to reflect
together, identify problems and resources, and find fruitful manners to use re sources to solve
problems. Results: In total 26 individuals were included, the obtained data is qualitative and our
results show that many of the co-morbidity problems found were highlighted for the first time.
The possibility to meet and make common plans for future treatment was much appreciated by a
vast majority of the network and the patients. Conclusion: A coordinated examination will lead
to a coordinated treatment, resulting in an improvement of health and life situation in dual
disorder clients.
34.
Ethnicity AND compulsory admission in a Psychiatric Inpatient Population
Graça Cardoso, Joana Alexandre, Raquel Ribeiro
Department of Psychiatry, Hospital Fernando Fonseca, Amadora, Portugal
There is evidence that ethnicity influences the clinical characteristics, the diagnosis, and the
treatment of patients admitted to psychiatric departments. Objective: The current study was
aimed at assessing the impact of ethnicity in inpatients’ clinical characteristics and management.
Methods: The medical records of all the consecutive patients admitted to a psychiatric inpatient
unit between January 1, 2004 and June 30, 2007 were reviewed to assess age, gender, ethnicity,
discharge diagnosis, length of stay (LOS), number of compulsory admissions, and number of
readmissions. Results: In the period of time studied 977 patients, corresponding to 1382
admissions, were admitted to the unit. Black patients represented 19.6% of the psychiatric
inpatients, and were younger (35.9±16.7 vs. 45.8±12.7 years, p<.001), more frequen tly male
(60.2 vs. 43.8%, p<.001), had more compulsory admissions (15.7 vs. 10.8%, p=.022), and on
average a longer LOS in the unit (22.7± 20.0 vs. 18.8± 20.3 days, p=.005), when compared with
white inpatients. The two groups did not differ in the number of readmissions. There were
78
statistically significant differences in the diagnosis distribution, with black inpatients being more
frequently diagnosed with schizophrenia and acute psychosis, and less frequently with delusional
and personality disorders, than white inpatients. Conclusions: The results confirm those of
previous studies, and highlight the need for differentiated and more culturally sensitive care in
mental health services. The first contact with the patient in the context of acute psychosis, is
particularly important in order to avoid, whenever possible, compulsory admission and stigma.
35.
Effects Of Sustained Compulsory Hospital Treatment For ‘Untreatable’ Chronic Addiction
And Mental Health Patients
Rob van den Brink1 John Hoogeveen2 Niels Mulder3 Matty de Wit4 Durk Wiersma1
1
University Medical Center Groningen 2Mental Health Organization Drenthe 3Erasmus Medical
Center Rotterdam 4Municipal Health Authority Amsterdam The Netherlands
Objective: A group of chronic patients, with both addiction and mental health problems, are
considered ‘untreatable’ within current services. These patients have been treated by all available
means, including compulsory hospital treatment, but have not gained from these efforts, and
often have been discharged because they proved unmanageable within regular hospital settings.
They live on the street, and cause considerable inconvenience to their surroundings. The
municipalities of Amsterdam and Rotterdam joined hands to create a new treatment facility for
these patients, called ‘Enduring Residence’ (ER). Patients are compulsory admitted to ER, for as
long as necessary (and supported by the judge), and are offered divers treatment, targeting their
somatic, addiction, psychiatric, and psychosocial problems.Methods: In a quasi-experimental
study the effect of ER is compared to that of regular care for patients meeting the same criteria
but living in Utrecht or The Hague. Both research groups will consist of 100 patients, and are
followed for two years. Primary outcome is the number of patients who reach a reasonably stable
level of functioning in the community. Functioning is assessed with the HoNOS, and clients are
interviewed about their quality of life and subjective experience of the compulsory treatment.
Police records will be screened for any inconvenient or criminal behaviour of the patients.
Finally, the costs of both treatments are compared.Results: The design of the study will be
presented in the poster. Conclusions: ‘Enduring Residence’ is an innovative form of treatment,
for an extremely difficult group of patients to treat.
36.
Community Versus Hospital Inpatient Treatment of Adolescent Anorexia Nervosa:
Chalenging Established Beliefes
Sarah Byford,1 Barbara Barrett,1 Chris Roberts,2 Andrew Clark,3 Vanessa Edwards,4 Nicola
Smethurst,4 Simon Gowers4
King’s College London2 University of Manchester3 Bolton, Salford and Trafford Mental Health
NHS Trust4 University of Liverpool
1
Objective: Young people with anorexia nervosa are often admitted to hospital for treatment,
despite little research evidence to demonstrate benefits of admission. As well as being disruptive
to school, family and social life, inpatient treatment is a relatively expensive option. This study
compares the cost-effectiveness of inpatient psychiatric treatment, specialist outpatient treatment
and general outpatient treatment for adolescents with adolescent depression. Methods: UK
multi-centre randomised, controlled trial. Outcomes and costs were assessed at baseline, one and
two years. Results: 167 young people were recruited to the trial. There were no statistically
significant differences in clinical outcome between the three groups at 2 years. The specialist
outpatient group was less costly over the 2-year follow-up (mean total cost £26,738) than the
inpatient (£34,531) and general outpatient treatment (£40,794) groups, but this result was not
79
statistically significant. Exploration of the uncertainty associated with the costs and effects of the
three treatments suggests that specialist outpatient treatment has the highest probability of being
cost-effective. Conclusions: On the basis of cost-effectiveness, these results support the
provision of specialist outpatient services for adolescents with anorexia nervosa.
80